[dr.Ira]

Ув. педиатры!
На форуме терапевтов есть пилюлька от Нескучина. Предлагаю у нас на форуме ее детский вариант.
Для начала вот такой вопрос:
A 17-year-old woman comes to the office complaining of a 3-month history of "crampy" abdominal pain along with alternating episodes of constipation and diarrhea. She reports that the pain has been worse recently since starting a new job, which she describes as "high stress." Pain also seems worse with eating fatty meals. Her temperature is 37.0 C (98.6F), blood pressure is 120/72 mm Hg, pulse is 63/min, and respirations are 10/min. Physical examination reveals a soft, non-tender, non-distended abdomen with normal bowel sounds and without organomegally. Her rectal exam reveals normal tone. The correct diagnosis would be supported by finding
A. a biopsy with transmural intestinal inflammation
B. fistula formation within the abdomen
C. a history of bloody diarrhea
D. a normal colonoscopy
E. positive H. pylori antibody titers

[Tim Vetrov]

Думаю, что это синдром раздраженной толстой кишки, т.е. D.
С другой стороны, не вполне понятна локализация болей. М.б. и гастрит или дуоденит, тогда E. Но вообще говоря, для гастрита характерна болезненность при пальпации.
Нет, все-таки D.

[yananshs]

По-мoему тоже D.

[Nancy]

Тим, возможно. Но что-то мне кажется, что и на НЯК похоже. Так что - будь, что будет:) - вариант С

[Tim Vetrov]

Насчет НЯКа, меня остановил совершенно спокойный живот при пальпации, да и при ректальном обследовании все хорошо.

Немного смущает, правда, тот факт, что ей кажется, что похуже от жирной пищи (это ведь тест, а в тесте, как в сказке про Алису, все не просто так), но все равно физикально при НЯКе что-то должно находиться...

[Nancy]

Тим, тоже верно. Однако характер у меня дурной - самый "напрашивающийся" вариант отметаю сразу и ищу подвох))) Кроме того, что при пальпации живот спокойный и нормы при ректальном исследовании, все остальное при наличии диареи с кровью очень похоже на НЯК. Хотя вполне возможен и воспалительный процесс.

[dr.Ira]

Explanation:The correct answer is D. This patient has irritable bowel syndrome (IBS). This is the most common functional GI disorder. It is characterized by abdominal pain with alternating diarrhea and constipation. It is often related to stress or exercise. Diagnosis is made by history and thoughtful exclusion of other organic diseases. Colonoscopy, if performed, should be normal. Indication for colonoscopy would be to differentiate irritable bowel syndrome from inflammatory bowel disease.

Transmural inflammation (choice A) and fistula formation (choice B) is typical of Crohn disease. Crohn disease is characterized by inflammation of any part of the gastrointestinal tract (mouth to anus). Patients often have lesions, which are not continuous, described as skip lesions. The inflammation is transmural, which means that it involves all layers of the mucosal wall contrary to UC. Patients typically present with non-bloody diarrhea, weight loss, and abdominal pain.

Bloody diarrhea (choice C) is a finding in ulcerative colitis (UC). UC is characterized by inflammation limited to the colon and rectum and is typically described as continuous (as opposed to "skip" lesions). Bloody diarrhea is the typical presenting symptom.

H. pylori (choice E) may be a cause of abdominal pain and its eradication is recommended if it is discovered incidentally, but routine serology checks in the work-up of abdominal pain is of unproved benefit.

[dr.Ira]

4 вопроса про судороги.

Q1] The parents of a 2-year-old come in to discuss their child's febrile seizures. The child has experienced four seizures, each associated with fever (usually from an ear infection). Each seizure lasted less than 2 minutes and was generalized tonic-clonic. The child was usually post-ictal for about 60 minutes but then returned to his normal level of mental function. The parents are concerned about the long-term significance for these seizures, specifically about any permanent brain damage and retardation. They ask if their child should be on medication to prevent the seizures.

Which one of the following should you tell them?

A) Children with a history of febrile seizures usually go on to a more complicated seizure pattern as they age.
B) Children with a history of febrile seizures typically perform less well on standardized school tests.
C) Children with febrile seizures typically are growth retarded.
D) Children with febrile seizures are at greater risk for premature death than the general public.
E) Most children who experience febrile seizures develop normally.



Q2] You receive a telephone call from a worried mother. She says her 8 month old son just had a seizure lasting for 2 minutes.The seizure has subsided.He is feeding well. His temp 103 RR: 34/min
She asks you what needs to be done. You say:

A] Take him immediately to the nearest ER
B] This is nothing serious. Stay calm
C] Give antipyretics to the child and monitor the temp.



Q3] Mother in Q2 asks you what is the risk of her child developing a recurrent febrile seizure now. You say:

A] There is no such risk in your child
B] Risk is increased if his family member has a h/o febrile seizure
C] He will definitely have an increased risk since he already had one febrile seizure


Q4] Mother in Q2 also asks you, " Doctor. I am very worried. Does this episode of seizure increase my son's risk of developing future epilepsy?"
You should say:

A] Your child is definitely at increased risk of developing epilepsy
B] Your son will be at an increased risk if father has history of febrile seizures.
C] If another seizure occurs during this illness then he will be at increased risk
D]He will not have increased risk of developing future epilepsy.

[Nancy]

1.E(вариант А - возможно, но не обязательно)
2.C
3.C
4.D или С

[Dr. W.N.]

E, C, C, D
Из фаренгейта пересчитывал вручную, какой ужас :eek:

[yananshs]

Из Фаренгейта не надо пересчитывать. Я никогда не пересчитываю.:)
E, C, C, D.

[Mara___dok]

Е,А,С,D.По поводу второго вопроса,конечно,можно дискутировать.Но ребенок до года с впервые возникшими судорогами все-таки должен быть госпитализирован.

[Dr. W.N.]

Е,А,С,D.По поводу второго вопроса,конечно,можно дискутировать.Но ребенок до года с впервые возникшими судорогами все-таки должен быть госпитализирован. Не факт. При наличии в окружении врачей, читающих aafp.org, вполне можно на них оставить.

[denis_doc]

Не факт. При наличии в окружении врачей, читающих aafp.org, вполне можно на них оставить.
даже несмотря на наличие таких врачей, есть еще начмеды, главные врачи и прочия, которые читают только местечковые методички. Я знаю, вы знаете, но есть распоряжение о том, что любой ребенок с любыми "судорогами впервые" - должен быть госпитализирован. Все не так просто...

...ах, да: ECCD

[Dr. W.N.]

Ну мы сейчас не об этом, все всё понимают.

[dr.Ira]

1 - E
2 - C
3 - B [ Remember having had one febrile seizure does not increase the risk of recurrence but family history does. ]
4 - C. If the pt has no risk factors you can say that he will not have increased risk. Apparently, the pt in Q does not have risk factors. But choice C says what if another seizure occurs during this same illness?....then he will be at increased risk. [ refer to risk factors in above notes ]. So this would be ur best response [ Save your skin ]
Family h/o febrile seizure is not a risk factor for future

[Mara___dok]

Все-таки не очень понятно какое отношение имеет риск по эпилепсии к фебрильным судорогам,даже если они возникнут в течение той же болезни.(по поводу пункта 4).Или это мой английский так сильно хромает? :)

[Nancy]

Мара_док, не хромает, это, видимо, существует такая статистика. Наверное, она отражает склонность к формированию эпилептогенных очагов у тех детей, у которых повышена судорожная готовность. Простите, если что не так сказала - не специалист.

[Mara___dok]

Я в этом вопросе тоже не специалист.Просто нас учили,что существует эпилепсия,существует эпилептический синдром при разных состояниях,в том числе при высокой температуре.И одно к другому отношения не имеет.Но теперь я уже во всем сомневаюсь. :)
Может быть кто-нибудь из уважаемых невропатологов прокомментирует.

[Nancy]

Существуют эпилептиформные припадки, и не обязательно при повышении температуры, про эпилептический с-м не слышала.

[Dr. W.N.]

При атипичных фебрильных судорогах повышается риск возникновения гиппокампального склероза - одной из частых причин эпилепсии. См. [Ссылки могут видеть только зарегистрированные и активированные пользователи]

[Mara___dok]

Василий Юрьевич,спасибо за ссылку.Но в задачке нигде не сказано.что судороги атипичные,точнее на это нет никаких указаний,их ведь видела только мама ребенка.Правильно я поняла?Но они возникли при высокой температуре,быстро самостоятельно купировались...Но задача есть задача.В них всегда присутствует определенная условность.

[Dr. W.N.]

Повторные ФС относятся к сложным (простите за термин "атипичные"), прогностически менее благоприятным.
Упоминание о гиппокампальном склерозе я привел как наиболее распространенную гипотезу, это не единственное объяснение возможных механизмов эпилептогенеза, которое, к тому же, многими оспаривается.
P.S. Я все это пишу, а сам то пропустил в вопросе условие о повторении судорог. Так что пойду я лучше на дежурство. :(

[Mara___dok]

Спасибо,Василий Юрьевич!
Но в условии то как раз и нет ничего про повторение судорог.А речь идет о том,что они еще только могут повториться и поэтому предлагается сказать,что вероятность эпилепсии будет выше.Подстраховаться.А вот подстраховаться с госпитализацией не предлагается. :) Спокойного вам дежурства! :)

[Dr. W.N.]

C] If another seizure occurs during this illness then he will be at increased risk
Я эту фразу тоже сначала пропустил. Первое слово тут ЕСЛИ. И это варианты ответа маме. Так что все сходится.
P.S. Неужели только у нас считается дурной приметой желать удачного дежурства? :( Буду теперь знать, кто мне сглазил. :mad:

[Mara___dok]

Простите великодушно!Больше не буду!

[dr.Ira]

A 2-month-old boy is brought to the office for a routine well-baby visit. The mother tells you that he is doing very well, that he drinks 5 oz of formula every 4 hours, stools twice a day, and sleeps 6 hours at a time. His temperature is 37.0 C (98.6 F). Physical examination is normal and he is growing along the 50th percentile for height and weight. After addressing all of the mothers questions and concerns, the most appropriate next step in management is to
A. administer the DTaP, haemophilus-hepatitis B, inactivated polio, and pneumococcal “conjugate” vaccines
B. obtain a bagged urine specimen to check for reducing substances
C. order a complete blood count to evaluate for anemia
D. send the patient home with his mother for a return visit in 2 months
E. send the patient home with his mother and schedule a return visit in 3 weeks

[antibiotik]

Полез в календарь прививок и решил А, хотя перед А надо бы В и С.
А сколько правильных ответов? один или много?

[dr.Ira]

А сколько правильных ответов? один или много?
Oдин.

[Nancy]

Думаю, что А

[Mara___dok]

Добрый день!
Насколько я знаю,введение пневмококковой вакцины не рекомендуется до двух лет,поэтому скорее всего ответ - С.

[dr.Ira]

The correct answer is A. The 2-month visit is the visit of first vaccines. The initial vaccines are DTaP, Hib-Hep B, IPV, and pneumococcal vaccines.

A bagged urine specimen (choice B) is not routinely obtained.

A complete blood count (choice C) is usually done at about the 9 month visit, not at 2 months.

After the initial set of vaccines, the patient may be sent home with a follow up in 2 months. Without the vaccines, it is inappropriate management to send him home for a return visit in 2 months (choice D) or with a return visit in 3 weeks (choice E).

[dr.Ira]

A 3-year-old boy is brought to the office because of a 2-day history of fever, nausea, weakness, and "yellow skin." He has always been a healthy child, rarely having more that a sore throat or ear infection. The family has not traveled recently and no other family members are sick. A couple of children in his childcare center are sick and a parent of one of the other children has similar symptoms. His temperature is 38.1 C (100.6 F). Physical examination shows icteric skin and conjunctiva but is otherwise unremarkable. Laboratory studies show:

IgM Anti-HAV Positive
HbsAg Negative
HCV-Ag Negative

You should advise the mother that:
A. Hepatitis vaccination that is routinely recommended for all children in the United States would have prevented this illness
B. Her son can return to childcare 5 days after the onset of symptoms
C. Household contacts should receive immune globulin within 2 weeks after last exposure
D. It is likely that her child was sexually abused by his friend's father
E. There is a 30% chance that her son will develop chronic hepatitis

[AlexGold]

Насколько я знаю,введение пневмококковой вакцины не рекомендуется до двух лет,поэтому скорее всего ответ - С. Это верно для полисахаридной неконъюгированной пневмококковой вакцины, как и вообще для всех полисахаридных неконъюгированных вакцин - они слабоиммуногенны у детей до 2-х лет жизни. В вопросе речь идет о конъюгированной пневмококковой вакцине, которая, как и все конъюгированные вакцины, иммуногенна с 2-х мес. жизни и с этого возраста и применяется в национальных календарях некоторых стран.

[Mara___dok]

Александр,спасибо за объяснение. :)

[birdname]

IgM Anti-HAV Positive
HbsAg Negative
HCV-Ag Negative

Я за "С" - иммуноглобулин контактным.

[Nancy]

Я тоже за С

[Tim Vetrov]

А разве в США вакцинация против гепатита А не включена в календарь?
Я, вообще-то, скорее за А; во всяком случае, я против того, чтобы всем контактным вводить иммуноглобулин в такой ситуации.
В новых СП, насколько я помню, предусмотрена вакцинация контактных.

[Nancy]

Ребенок уже болен(вероятно, он не был вакцинирован ранее). Поэтому вакцину Вы ему вводить не будете. Вариант А не подходит.

[OrFun]

А.
Там , как я понимаю , речь идет о том, что вакцинация могла предотвратить это заболевание .

[Tim Vetrov]

Ребенок уже болен(вероятно, он не был вакцинирован ранее). Поэтому вакцину Вы ему вводить не будете. Вариант А не подходит.
В пункте "А" написано, что рутинная вакцинация против гепатита, проводимая детям в США, могла бы предотвратить это заболевание.
Если бы написано было "в мире", то этот пункт однозначно не годится, т.к. в международный календарь входит только вакцина против гепатита В.
В США, как мне кажется, вакцинируют по календарю и от гепатита А.
Так что вариант "А" вполне приемлем.

[dr.Ira]

The correct answer is C. This patient has an infection with the hepatitis A virus, which is usually transmitted by the fecal-oral route. Since young children tend to put many things in their mouths, including dirty fingers, it is not hard to imagine how they can contract this disease. It can also occur from contaminated food and water, international travel, and rarely through homosexual activity. The treatment is supportive. Household contacts should receive immune globulin within 2 weeks after last exposure.

The hepatitis vaccination that is routinely recommended for all children in the United States would have prevented this illness (choice A) is incorrect. The hepatitis B vaccine, not the hepatitis A vaccine, is routinely recommended for children in the U.S. Ну и, кроме всего прочего, он ведь уже заболел, так что уж теперь говорить, что могло бы быть ( не быть ), если бы...

It is incorrect to advise her that her son can return to childcare 5 days after the onset of symptoms (choice B). Children can return to childcare 7 days after the onset of symptoms.

While the hepatitis A virus may be transmitted through homosexual activity, you should not advise her that it is likely that her child was sexually abused by his friend's father (choice D). Close contact, not necessarily sexual contact, and fecal-oral transmission are the most likely sources of infection. Since you have absolutely no evidence that this child has been sexually abused, it is inappropriate to say this to the mother at this time.

Since hepatitis A is not associated with chronic infection, it is incorrect to tell the mother that there is a 30% chance that her son will develop chronic hepatitis (choice E).


P.S. В Израиле привика от гепатита А а в календаре прививок с 1998 г. ( Гепатит В с 1992 г.)

[AlexGold]

В США, как мне кажется, вакцинируют по календарю и от гепатита А. Именно так. Не далее как с начала 2006 г.

[dr.Ira]

The mother of a 3-year-old patient of yours, calls the office after the child banged his head against the coffee table in their family room. The mother is absolutely frantic, saying that her son has been "screaming and crying" for the past 45 minutes and that she cannot calm him down. She tells you that he did not lose consciousness. You advise her to bring him into the office, even though you just finished seeing your last patient and were just planning on leaving for the evening. When they arrive, you notice that the boy's eyes appear very red from crying, but that he has calmed down. The mother is still very concerned. They have both been patients of yours for many years, and they have always been very healthy and compliant. You notice that there is a 0.5-cm edematous area on the back of his head. The skin is intact over the wound. The remainder of the physical examination, including a complete neurologic and funduscopic examination, is unremarkable. After calming the mother down, the most appropriate next step is to
A. advise them to go to the emergency department for observation
B. obtain a skull radiograph
C. order a CT scan of the head
D. recommend regular monitoring and observation for any abnormalities, and if they arise, that they should go to the emergency department
E. report the case to the child protective service agency

[yananshs]

D......

[Dr. W.N.]

В жизни - D, но Е здесь тоже наверное не просто так... :confused:

[Tim Vetrov]

Да уж, так и представляю фразу врача: "Успокойтесь, мамочка, сейчас направим report of the case to the child protective service agency, и все будет отлично!"

[dr.Ira]

Explanation:

The correct answer is D. This boy has a minor closed head injury with no loss of consciousness, which is one of the most common injuries in children. All children "bump" their heads at some point. It is important to do a physical examination, including a complete neurologic and funduscopic examination, and if this is normal, be able to recognize that further studies are generally not indicated. Regular monitoring and observation for any abnormalities can be done by a competent caregiver. If this occurred during the day, you may consider having them stay in your waiting room for a little while, but since you are leaving for the night and the mother has always been responsible and compliant, you can send them home for observation.

It is inappropriate to advise them to go to the emergency department for observation (choice A). This child had a minor head injury with no loss of consciousness and he has a normal neurologic and funduscopic examination. It is very unlikely that he has an intracranial injury, and therefore, as long as you know that the mother is a competent caretaker, you should send them home after advising her to seek assistance if he begins to deteriorate.

It is unnecessary to obtain a skull radiograph (choice B) at this time in this child with a minor closed head injury without a loss of consciousness. He does not have any signs of a skull fracture, which include battle signs (ecchymoses behind the ear), a palpable depression, or blood in the ear and therefore it is very unlikely that the radiograph will show a skull fracture. Also, even if he did have a skull fracture that does not necessarily mean that he has an intracranial injury.

A CT scan (choice C) is not indicated at this time in this patient with a minor closed head injury, no loss of consciousness, and a normal neurologic and funduscopic examination. Studies have shown that the risk of intracranial injury is negligible in this situation, and that fewer than 1 in 5,000 patients with minor closed head injuries and no loss of consciousness have intracranial injuries that require medical or neurosurgical intervention.

Since this case states that they are very healthy and compliant patients and the physical exam does not reveal any abnormalities besides this head wound that seems consistent with the story the mother told you, it is inappropriate to report the case to the child protective service agency (choice E). It is always important to be aware of signs of child abuse, such as many emergency room visits, many wounds in various stages of healing, implausible and inconsistent stories, and bringing the child in a while after the injury took place. This case does not seem to fit this description

[dr.Ira]

A 6-year-old boy is brought to the office by his parents who are concerned because he has been refusing to use his left arm for 1 day. The parents report that he has been in good health and has not suffered any recent falls or injuries to the arm that they are aware of. The father does recall one incident 2 days ago when he pulled upward on the boy's right arm to prevent him from tripping as they descended a flight of stairs. The boy is holding his right arm with the elbow flexed and the forearm pronated. He begins to cry when you attempt to examine the arm. The most appropriate next step is
A. closed reduction and cast immobilization
B. a CT of the right arm
C. measurement of compartment pressure of the forearm
D. supination of the forearm with the elbow flexed
E. a trial of compressive bandage on the right arm

[riltsov]

Вывих локтевого сустава.
A. closed reduction and cast immobilization

[denis_doc]

A. наиболее вероятно.

[antibiotik]

Д. Иммобилизации не нужно, наоборот, нужно давать ребенку игрушку, чтобы оценить движения в конечности, и, следовательно эффективность манипуляции.
Дз: подвывих головки луча.

[Nancy]

А нельзя рентген сделать?)))
Можно попробовать пункт Е, а потом сделать снимок.

[dr.Ira]

Explanation:

The correct answer is D. This boy has the signs and symptoms of a very common injury in little children. "Nursemaid's elbow" or subluxation of the radial head, which occurs when there is longitudinal traction on the pronated extended elbow. This traction can cause the radial head to slip from beneath the annular ligament. Children will often refuse to move the arm following this injury. X-rays of the forearm and elbow are usually normal and treatment involves supination of the forearm with the elbow flexed. Recurrence is uncommon and no immobilization of the affected arm is necessary.

Closed reduction and cast immobilization (choice A) is necessary for fractures of the forearm, not for subluxation of the radial head. Fractures of the forearm are also very common in children, but usually have an antecedent history of fall or injury.

Obtaining a CT of the right arm (choice B) is not necessary for this patient. X-rays of the right arm can be done to rule out a fracture or hemarthrosis. A CT of the extremity is sometimes performed if the x-ray demonstrates a fracture. The history given by the boy's parents and the boy's presenting symptoms strongly suggest subluxation of the radial head. X-rays of the forearm and elbow are usually normal in this setting and are not necessary to make the diagnosis.

There is no reason to suspect compartment syndrome (choice C) in this child. Signs of compartment syndrome include severe pain in the limb especially with active or passive stretching of the ischemic muscle, cyanosis, and numbness. This syndrome is an uncommon complication of any traumatic injury to the extremities. Subluxation of the radial head is not associated with compartment syndrome.

A trial of a compressive bandage (choice E) is not necessary in this patient. Supination of the forearm should reduce the subluxation of the radial head. Compressive bandages or immobilization are not necessary after reduction of the subluxation.

А, кстати, что не совсем типично в условии в этой задачке? :p

[antibiotik]

Кстати да, совсем не посмотрел на возраст ребенка, 6 лет, обычно такая травма у детей в полтора-два года.

[dr.Ira]

Я нашла в сети вариант экзамена на Step.3 Два минуса: он на каком-то Acrobat'е, поэтому скопировать через copy-paste не получается. :( И второй минус - правильные ответы есть, но без объяснений.
Я на работе уже второй день эти задачки отгадываю (и не без удовольствия :) ).
Если хотите, могу по нескольку штук выкладывать и здесь.

[Dr.Nathalie]

Ира! Для того, чтобы скопипастить из акробата, нажми на кнопку TEXT в меню, тогда дурацкая "ладошка" исчезнет, и ты сможешь выделить и скопировать любой текст.

[dr.Ira]

Thanks! Завтра попробую. :)

[dr.Ira]

Наталья, тебе отдельное спасибо!
Выкладываю первые 10 вопросов. Дерзайте! (с) :)

1. A 21-year-old man comes to the clinic because he has become increasingly short of breath and has had a cough for the past week.
He appears dyspneic and has a temperature of 38.3EC (101.0EF). On physical examination he has bibasilar rales and generalized
lymphadenopathy (1 to 2 cm). Rectal examination shows multiple perianal contusions and a small amount of blood oozing from the
anal orifice. Chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate course of action is to order blood tests
and to do which of the following?
(A) Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
(B) Admit him to the hospital and begin administration of penicillin and gentamicin, intravenously
(C) Begin administration of erythromycin, orally, and see him again the next day
(D) Prescribe isoniazid and rifampin, orally
(E) Recommend aspirin, fluids and rest at home

2. A 17-year-old white girl returns to the health center for a family planning follow-up visit. She gave birth to a healthy baby girl 8
months ago and does not want to become pregnant again. She is monogamous with the father of her baby but worries that he is not
monogamous with her. They live together and are not married. She is taking an oral contraceptive and "sometimes" uses condoms.
She says that she has great trouble remembering to take her pills and wants to discuss other contraceptive options. In addressing this
issue, which of the following is the most appropriate next step?
(A) Advise her to continue taking an oral contraceptive because it is one of the most effective methods of birth control
(B) Advise her that an intrauterine device would be a good contraceptive choice for her
(C) Discuss implantable or injection long-term progestational contraceptive agents
(D) Discuss the option of tubal ligation
(E) Fit the patient with a diaphragm and instruct her on proper use

3. A 19-year-old African-American college student comes to the student health center because of marked fatigue. Temperature is
38.3°C (101.0°F). Physical examination shows striking pallor of skin, nail beds and conjunctivae. There are petechial hemorrhages
in the skin of his legs. A soft, blowing systolic murmur is present over the precordium. No other abnormalities are present. Which
of the following is the most appropriate study at this time?
(A) Complete blood count
(B) Determination of bleeding and clotting time
(C) Examination of bone marrow aspirate
(D) Hemoglobin electrophoresis
(E) Serological testing for infectious mononucleosis

4. A 12-year-old girl is referred to the clinic by the school nurse for evaluation of scoliosis. The girl's scoliosis was detected during a
routine screening examination at the school, and it appears to be mild (curve less than 10 degrees). She is athletic and is otherwise
in good health. During the physical examination, particular attention should be given to which of the following?
(A) Arm length
(B) Blood pressure
(C) Body weight
(D) Cardiac examination
(E) Stage of pubertal development

5. A 10-month-old infant is brought to the health center by his mother because of eight watery bowel movements during the past
24 hours. On physical examination the infant is lethargic and somnolent. The mucous membranes are dry and the skin turgor is
poor. The anterior fontanel is sunken. At his last visit 2 weeks ago, he weighed 10 kg (22 lb); today his weight is 9 kg (20 lb). His
temperature is 37.2EC (99.0EF), pulse is 170/min and blood pressure is 100/60 mm Hg. Which of the following is the most
appropriate next step in management of this infant?
(A) Begin intravenous hydration with isotonic saline solution
(B) Educate the mother on how to recognize dehydration and worsening clinical symptoms in her infant
(C) Obtain serum electrolyte concentrations and begin oral rehydration therapy
(D) Obtain a stool culture and begin amoxicillin therapy
(E) Tell the mother to stop breast-feeding and have her give the infant a soy-based formula

[dr.Ira]

43
A 45-year-old woman is brought to the health center by her husband because of nausea, confusion, chills, fever, flank pain and cloudy
urine. She has a history of insulin-dependent diabetes mellitus, poorly controlled hypertension and recurrent urinary tract infections. Her
vital signs are:
Temperature 40.0°C (104.0°F)
Pulse 120/min
Respirations 24/min
Blood pressure 110/70 mm Hg
Funduscopic examination shows diabetic retinopathy, which is unchanged from the previous examination. Neck is supple. Lungs are clear
to auscultation and percussion. Examination of the abdomen is normal. Marked pain is present at the right costovertebral angle. Several
hemorrhagic bullous lesions are noted on the extremities.
6. Without prompt and aggressive treatment, this patient is most likely to develop which of the following?
(A) Diabetic ketoacidosis
(B) Hyperosmolar coma
(C) Meningitis
(D) Pneumonia
(E) Septic shock

7. If this patient were to develop anuria, which of the following would be the most likely cause?
(A) Acute papillary necrosis
(B) Bladder outlet obstruction
(C) Neurogenic bladder
(D) Renal lithiasis
(E) Tumor encroachment on the ureters
END OF SET

8. A 23-year-old registered nurse comes to the employee health clinic because she says, "I'm too tired to work." She has had
increasing fatigue, malaise and anorexia during the past several days. Laboratory studies show:
Serum Blood
ALT 1160 U/L PT 13 sec
Bilirubin 1.8 mg/dL
HBsAg Positive
She is instructed to rest at home and return in 3 days if no new symptoms develop. Two days after the visit she calls to say that she
has now developed an urticarial rash and swelling of the joints of her fingers. At this time which of the following is the most correct
statement about her condition?
(A) The arthritis and rash are the result of an associated immune complex disorder
(B) The arthritis and rash are unrelated to her liver disease
(C) It is unlikely that her blood is infectious
(D) She has a 50% risk for developing chronic liver disease
(E) She should be given hepatitis B immune globulin

9. A 47-year-old Italian-American man comes to the office for the first time for routine medical care. He has been referred to you by
his psychiatrist who has informed you that the patient has paranoid personality disorder. The patient has no other medical problems
at this time. He is unmarried, lives alone and has no close friends, but he occasionally attends family gatherings. He functions well
working alone in a technical position in an engineering firm. Which of the following is the best way to structure the
physician-patient relationship with this patient?
(A) Avoid giving him excessive details about possible, but infrequent, side effects and complications in order to avoid
triggering his paranoia
(B) Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional,
but not overly friendly stance
(C) Go out of your way to be warm and friendly so that he can develop trust in you
(D) Have his psychiatrist, with whom he has been working for several years, take the lead in presenting medical treatment
options
(E) Try to communicate with his family or medical personnel when he is not present in order to overcome his withholding
information because of distrust

10. A 12-month-old boy is brought to the office by his mother for his routine health check-up. She informs you that she has just been
diagnosed with hypercholesterolemia. Her fasting serum total cholesterol concentration was 260 mg/dL and her LDL-cholesterol
concentration was 130 mg/dL (rec<129 mg/dL). She is unaware of a family history of coronary artery disease because she was
raised by her godmother when her parents died in their early 30s in a motor vehicle accident. A special diet has been recommended
for her; however, she is very concerned about the risk of hypercholesterolemia for her son. Which of the following is the most
appropriate management at this time?
(A) Ask her to reduce the child's fat intake and give him skim milk instead of whole milk
(B) Do nothing until the child is 2 years of age
(C) Have the child return for a fasting lipoprotein analysis
(D) Obtain a random serum total cholesterol concentration for the child today
(E) Refer the child to a lipid specialist

[Nancy]

1.Поскольку вполне вероятно, что мы наблюдаем ВИЧ-ассоциированную пневмонию, то - А
2.Думаю, С
3. Д - для исключения гемоглобинопатий, часто встречающихся у выходцев из Африки.Хотя А тоже необходимо сделать.
4.Возможно, Е
5.А

6.А
7.А. Но, насколько я помню, у диабетиков почечная недостаточность развивается на фоне гломерулосклероза.Такого варианта нет)) Поэтому рискну предположить, что в данном случае некроз разовьется на фоне острого нарушения микроциркуляции.
8.По-моему, А
9.С или Д
10.А

[riltsov]

1. Пневмоцистная пневмония. (A) Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
2. (A) Advise her to continue taking an oral contraceptive because it is one of the most effective methods of birth control
3. Может сначала, (A) Complete blood count, чтобы посмотреть в нем тромбоциты, эритроциты.
4. (E) Stage of pubertal development.
5. (A) Begin intravenous hydration with isotonic saline solution. Однозначно!
6. (E) Septic shock
7. (B) Bladder outlet obstruction
8. (A) The arthritis and rash are the result of an associated immune complex disorder
9. (B) Explain the rationale for any diagnostic procedures and treatment regimens in some detail, adopting a professional,
but not overly friendly stance
10. (A) Ask her to reduce the child's fat intake and give him skim milk instead of whole milk

[Mara___dok]

1)А.
2)С.Хотя не слышала,чтобы у нас этот способ применялся.
3)Как то хочется и время кровотечения,и полный анализ крови,но скорее всего правильный ответ D.
4)А.
5)А
6)Е
7)А.
8)А.
9)Не сталкивалась с такими проблемами.
10)А.

[OrFun]

1.А
2.С или Е ?
3.Первым шагом ,наверное, все-таки А(позволит снять много вопросов .Перед Д - например ,можно в общем анализе определить MCHC...).А потом ,наверное и длительность кровотечения с временем свертывания
4.С
5.А
6.Е
7.А (на фоне сепсиса возможно поражение канальцев...?)
8.А
9.В или Е
10.Е

[dr.Ira]

Правильные ответы :
1.А
2.С
3.А
4.Е
5.А
6.Е
7.А
8.А
9.В
10.В.

Есть ответы, которые хотелось бы обсудить?

[Nancy]

Др.Ира, спасибо!
Только с последним вопросом хотелось бы разобраться. Я не педиатр, и мне интересно - почему именно до 2-х лет можно ничего не предпринимать?

[Anna_Shvedova]

можно я робко попрошу?
очень трудно (может быть, только мне, в силу отсутствия необходимых талантов), когда столько задач и список буковок потом..
нельзя ли их выкладывать штуки по три, а не по десять?

[dr.Ira]

почему именно до 2-х лет можно ничего не предпринимать?
The NCEP (The National Cholesterol Education Program) has recommended a selective approach in screening children for hypercholesterolemia. Screening should be performed in children more than two years of age who have a positive family history of premature cardiovascular disease or parental hypercholesterolemia. ([Ссылки могут видеть только зарегистрированные и активированные пользователи] )
Это рекомендации NCEP. Думаю, что решающим является соотношение цена вопроса/риск развития cardiovascular disease. Хотя, впрямую об этом нигде ( в доступных мне источниках :) ) не говорится.

[Nancy]

Спасибо! Пойду проверять холестерин, поскольку мне уже давно минуло 2 года, а наследственность "дурная")))

[dr.Ira]

Поскольку, это, все-таки, "детская пилюлька", я буду выкладывать только те вопросы, где "главные герои" - пациенты до 18 лет. А про взрослых пускай уж Яна рассказывает ( чтобы не дублировать темы ). :)


14. A 15-year-old boy comes to the office for a sports participation physical examination. He has been playing in a summer basketball
league and now wants to try out for the high school team. His last physical examination was 2 years ago and, according to him, he
has been healthy except for a cold 2 weeks ago. Before you begin the physical examination, the nurse informs you that his routine
urinalysis shows:
Color Tea-colored/dark WBC 7/hpf
Specific gravity 1.030 RBC >100/hpf, a few red cell casts
pH 5.5 Bacteria Negative
Protein 2+ Glucose Negative
Ketones Negative
These laboratory results are most indicative of which of the following?

(A) Cystitis
(B) Glomerulonephritis
(C) Nephrotic syndrome
(D) Pyelonephritis
(E) Renal calculi


15.A 16-year-old Anglo-American girl comes to the office because she has missed a menstrual period and a home pregnancy test was
positive. Bimanual examination discloses an enlarged uterus, and a urine pregnancy test is positive. She is estimated to be
approximately 6 to 8 weeks pregnant. You have been the family's physician since she was born. She asks that you please not tell her
parents. Which of the following is the most appropriate immediate response?

(A) Attempt to persuade her to share the information with at least one adult member of her family
(B) Explain that by law you are unable to maintain confidentiality
(C) Explore with her the reasons for her not feeling comfortable sharing the information with her parents
(D) Point out that she will not be able to hide her pregnancy for very long
(E) Reassure her, but notify her mother after she leaves



16. During a routine physical examination of a 2-week-old Jewish neonate, a grade 3/6 early systolic murmur is heard. The mother
reports no signs or symptoms of illness in the baby. The neonate is otherwise asymptomatic. Physical examination at birth was
normal. Which of the following is the most appropriate next step?
(A) Do funduscopic examination
(B) Measure arterial blood pressures in the arms and legs
(C) Order abdominal ultrasonography
(D) Order chest x-ray film
(E) Order electrocardiography

[Nancy]

1.А
2.Ситуация щекотливая.Наверное,Д
3.Е

[Anna_Shvedova]

В
С
хочу эхокг :( В?

[Mara___dok]

1.Скорее все-таки гломерулонефрит,есть указание на простуду две недели назад.
2.Наверное С.
3.Померяем давление на руках и ногах.Потом ЭКГ.Или наоборт?

[riltsov]

1. (B) Glomerulonephritis
2. (A) Attempt to persuade her to share the information with at least one adult member of her family. Такая позиция подчеркивает уважение к личности пациентки. Если в 16 забеременела, значит взрослая, и относиться к ней следует как к взрослой. Вариант C. мне не кажется оптимальным, все-таки 16 лет - несовершеннолетняя. Да и с пациентками старшего возраста я бы так этот вопрос не обсуждал.
3. (E) Order electrocardiography. Конечно, хочется эхо. Изменение соотношения давлений на руках и ногах будет не при всех пороках.

[dr.Ira]

Правильные ответы:
14. В. Кровь в моче ( тем более, у мальчика )+ белок + цилиндры в первую очередь наводит на мысль о гломерулонефрите.

15. С. Думаю, что правильность ответа здесь связана с законом и ментальностью.

16. В. В первую очередь надо исключить коарктацию. Кстати, феморальный пульс может и пальпироваться у такого ребенка .

[dr.Ira]

Items 27-29

An 18-year-old white high school student comes to the office in late August because of a stuffy nose for 1 week. He reminds you that he
has had severe hay fever in the fall for the past 10 years. Review of his chart shows that he has positive skin tests to ragweed, dust and dust
mites, and he is receiving maintenance immunotherapy with extracts of these antigens. He also takes over-the-counter antihistamines for
symptomatic relief. This regimen has not provided relief so far this season. Physical examination is normal, apart from clear rhinorrhea.
He is afebrile, and there is normal transillumination of the frontal and maxillary sinuses. In reviewing his medical records you note that
smears of his nasal mucus contained large numbers of eosinophils. There is no record of any extensive immunologic work-up. You tell
him that he now has either an early viral upper respiratory tract infection or the beginnings of his seasonal allergic rhinitis. You suggest
that he use a corticosteroid nasal spray plus his usual antihistamines as needed. The appropriate treatment is undertaken, but 4 days later
he returns because of a toothache and fever. On physical examination he has right facial fullness and pain below his eye when he leans
forward. There is tenderness in the region of the upper premolar and molar teeth on the right side. His temperature is 38.7EC (101.6EF),
orally. He has bloody, thick, green mucus coming from his right nostril. The remainder of his physical examination is normal. You suspect
maxillary sinusitis on the basis of the clinical findings.

27. Before beginning antibiotic treatment in this patient, it is necessary to first do which of the following?
(A) Confirm the diagnosis with CT films of the sinus
(B) Confirm the diagnosis with plain x-ray films of the sinus
(C) Confirm the diagnosis with transillumination of the sinus
(D) Request consultation with a dentist
(E) No additional steps are necessary

28. The appropriate steps are taken. In prescribing antibiotic therapy for this patient, it is most important to remember which of the
following?
(A) Antibiotics are ineffective unless there is a concomitant surgical drainage procedure
(B) He is likely to be allergic to penicillin
(C) He needs to take medication for more than 7 days
(D) Only bactericidal antibiotics are effective
(E) Ordinarily at least two antibiotics are given
He is treated and initially feels much better. However, soon thereafter he developed a headache, right ear pain and painful stiff neck; he
spikes a temperature to 39.3EC (102.7EF), orally. Extraocular movements are normal.

29. Which of the following is the most likely explanation for these new symptoms?
(A) Allergic reaction to the antibiotic(s)
(B) Associated meningeal inflammation or infection
(C) Development of cavernous sinus thrombosis
(D) Direct spread of infection from the maxillary to the mastoid sinus
(E) Obstruction of the orifice of the maxillary sinus with a mucous plug
END OF SET

[riltsov]

1. (D) Request consultation with a dentist
2. (B) He is likely to be allergic to penicillin
3. (D) Direct spread of infection from the maxillary to the mastoid sinus

[Mara___dok]

1.С
2.А
3.D

[брукса]

1.(D) Request consultation with a dentist
2.(A) Antibiotics are ineffective unless there is a concomitant surgical drainage procedure
3. C третьим сложнее.. Не могу в полной мере согласиться ни с одним из вариантов. Пусть будет (D) Direct spread of infection from the maxillary to the mastoid sinus

[dr.Ira]

Правильные ответы

27. Е. В любом случае, нужно назначать антибиотикотерапию сроком не менее, чем на 7 дней . Поэтому, Before beginning antibiotic treatment in this patient, ничего из предложенного не нужно.

28. С.
29. В.

[брукса]

Почему вот только первый вопрос Е?

[dr.Ira]

Потому что, независимо от того, будете Вы проводить все перечисленное или нет, в первую очередь, все-равно, надо назначать антибиотик. Вопрос же стоит, фaктически, нужно ли
(A) Confirm the diagnosis with CT films of the sinus
(B) Confirm the diagnosis with plain x-ray films of the sinus
(C) Confirm the diagnosis with transillumination of the sinus
(D) Request consultation with a dentist
(E) No additional steps are necessary
ПЕРЕД назначением антибиотика? - Нет, не нужно.

Нужно назначить антибиотик, а уж дальше - разбирайтесь, что привело к такой клинике.

[брукса]

ой.. я в них немного запуталась...
По поводу второго вопроса: мне кажется, все упирается в давний спор Яны с нашими ЛОР-врачами...
и вообще.. все равно остается ощущение, что я недопонимаю акценты или окраску :( вопроса, сформулированного на другом языке...

[Mara___dok]

Трудности перевода тоже имеют место.Не всегда понятно ,что собственно от тебя хотят :( Все-таки у нас обычно смотрит ЛОР в такой ситуации и решает нужно ли хирургическое вмешательство.

[Mara___dok]

Уважаемая dr.Ира !А можно еще задачек ?Очень интересно и полезно.Заранее спасибо. :)

[dr.Ira]

49. A 14-year-old boy is brought to the walk-in clinic by his father late on Saturday afternoon because his left ear is swollen and
painful. The boy's ear has been black and blue since he injured it in a wrestling match 3 days ago. Symptoms have increased
significantly following a repeat injury 3 hours ago. On physical examination, his left ear is markedly swollen and tender to
palpation. Which of the following is the most appropriate next step?

(A) Reassure him and start aspirin therapy
(B) Reassure him and start codeine therapy
(C) Recommend that he apply cold packs to the ear for the next 12 hours
(D) Recommend that he apply hot packs to the ear for the next 12 hours
(E) Refer him to a surgeon for immediate drainage of the lesion

Items 50-51
A 6-week-old infant is brought to the health center by his mother because of projectile vomiting. You have not seen this infant before
and the mother says he has not been seen by a physician since birth. Weight at birth was 3550 g (7 lb 13 oz) and physical
examination was normal. Examination today is normal except for weight, now 4000 g (8 lb 13 oz), and slight dehydration.

50. Which of the following is the most appropriate management for this infant?
(A) Elevate the head of his crib to relieve gastroesophageal reflux
(B) Order supine and decubitus x-ray films of the abdomen
(C) Order ultrasonography of the pylorus
(D) Order an upper gastrointestinal barium study
(E) Place him on a clear pediatric electrolyte solution

51. The appropriate diagnostic test is done and is equivocal. Which of the following imaging modalities necessary to help
diagnose this infant's illness is most operator-dependent?
(A) CT scan
(B) Radionuclide gastric emptying time studies
(C) Routine x-ray films
(D) Ultrasonography
(E) Upper and lower gastrointestinal barium studies

[Mara___dok]

49-Е
50-А.Скорее всего это рефлюкс,хотя надо исключать и пилоростеноз.
51-С

[dr.Ira]

51-С
The appropriate diagnostic test is done and is equivocal. Which of the following imaging modalities necessary to help
diagnose this infant's illness is most operator-dependent?
Суть вопроса - какое из обследований наиболее зависит от врача ( техника ), выполняющего обследование. (operator-dependent).

[Mara___dok]

Спасибо,за подсказку.Как-то не задумывалась в таком аспекте.Наверное все-таки УЗИ-D.

[брукса]

Гм.. по поводу 49 - там описан отек, но ухо "сине-черное" кажется? Если расценивать эту синеву как гематому - напряженные гематомы вскрывают - но ввиду свежей травмы, этого делать нельзя - С
прошу прощения.

(в дитях не сильна, но самый operator-dependent метод обследования ИМХО УЗИ)

[antibiotik]

49-е
50-с (больше похоже на пилоростеноз)
51-d (Узи)

[dr.Ira]

49 - E
50 - C
51 - D

[dr.Ira]

53. A 2-year-old boy who has recently become one of your patients is brought to the clinic by his mother for a follow-up visit of a
chromosome analysis done 1 month ago. This child has minor dysmorphic features, and growth and developmental delay.
Chromosome analysis showed a small unbalanced chromosome translocation, with extra chromosomal material at the tip of
chromosome 3. The cytogenetics laboratory requested blood samples from both parents for follow-up studies. The parents are
divorced, and the mother has custody of the child. The relationship between the parents is hostile. The mother has been tested
and has normal chromosomes without evidence of translocation. At today's visit, she reacts angrily when the issue of
contacting the child's father for testing is raised. She states that he abandoned them, and that he has no interest in his child.
She refuses to cooperate in contacting the father, who could be a translocation carrier. You do not know the father, but an
office worker told you that he lives in a nearby town. The mother says that he is living with a new girlfriend. Which of the
following is the most appropriate next step?

(A) Attempt to identify the father's physician and work with that physician to obtain chromosome studies on the
father
(B) Contact the father by telephone and arrange for him to give a blood sample at a local hospital
(C) Document your attempts to work with the mother but proceed no further, since you have no physician-patient
relationship with the father
(D) Help the mother deal with her anger and educate her regarding the potential benefit to her son and others if the
father's chromosome studies are done
(E) Send the father a letter (expressing few details about the patient) and suggest that he contact your office for an
appointment and further discussion of his child


54. An 18-month-old white infant is brought to the clinic because of pallor and irritability. Her mother says the infant's diet
consists almost exclusively of whole milk, approximately 40 oz per day. On physical examination, the infant has a pulse of
160/min, respirations of 50/min, and normal heart sounds with a grade 2/6 systolic ejection murmur. Liver is palpable 3 cm
below the right costal margin. Laboratory studies show:
Blood
Hematocrit 13%
Hemoglobin 3 g/dL
Mean corpuscular volume 48 µm3
Platelet count 400,000/mm3
Reticulocyte count 0.8% (N=0.5-1.5% of red cells)
WBC 12,000/mm3
Following appropriate evaluation, which of the following is the most appropriate treatment?

(A) Administration of oral folate therapy
(B) Administration of parenteral iron therapy
(C) Administration of parenteral vitamin B12 (cyanocobalamin) therapy
(D) Transfusion with packed erythrocytes
(E) Transfusion with whole blood

59. A 3-year-old boy is brought to the office by his father because of a 3-month history of decreased activity, poor appetite,
sporadic vomiting, clumsiness and speech regression. Since his birth his family has lived in an old area of the city where
there is demolition of old buildings. Examination of a peripheral blood smear is likely to show which of the following?

(A) Basophilic stippling of erythrocytes
(B) Degranulation of eosinophils
(C) Diminished numbers of platelets
(D) Howell-Jolly bodies
(E) Macrocytic erythrocytes

[Nancy]

53.Снова вопрос этического характера:) Е, наверное
54.Такой низкий гематокрит...Вариант Е
59.А?

[брукса]

49 - E
Почему?

[Dr.]

54.Такой низкий гематокрит...Вариант Е


WHOLE blood никто не переливает :)

[Nancy]

WHOLE blood никто не переливает :)
Ааа:)
Ну тогда эритроцитарную массу.

[Mara___dok]

59-А.Похоже на отравление свинцом.Ожидаем базофильную зернистость эритроцитов.

[dr.Ira]

Гм.. по поводу 49 - там описан отек, но ухо "сине-черное" кажется? Если расценивать эту синеву как гематому - напряженные гематомы вскрывают - но ввиду свежей травмы, этого делать нельзя - С
прошу прощения.

(в дитях не сильна, но самый operator-dependent метод обследования ИМХО УЗИ)
Перепроверила - правильный ответ Е. Объяснений там нет. Я тоже расценила это, как гематому, но я не знала, что ввиду свежей травмы, их нельзя вскрывать. А почему?

[Mara___dok]

По поводу уха,там кажется травма три дня назад?

[dr.Ira]

Там еще и повторная свежая травма 3 часа назад.

[Mara___dok]

53-Е
54-анемия связана скорее всего с микрокровотечениями при молочном перекорме.Перевести oral folate therapy не получается.нужна коррекция препаратами железа.В тяжелых случаях переливание эритроцитарной массы.
59-А.
Пойду совершенствовать свой английский.

[Nancy]

Меня все-таки очень смущает эта анемия...Либо для детей нормативы очень отличаются от "взрослых", либо ребенок на грани гибели... Гемоглобин - 3 г/дл, это 30 г/л, гематокрит вообще ни в какие ворота не лезет...

[Mara___dok]

Да,Наиля,я согласна,наверное тут есть какой-то подвох.Но один раз наблюдала девочку подростка,которая все лето пила козье молоко и больше почти ничего не ела.Гемоглобин был 60 г\л.В стационаре,где она лежала никаких причин анемии так и не нашли.Лечили парентеральным введением железа.Может быть и талассемия,а про молоко сказано,чтобы нас запутать?

[Nancy]

Мара, мне что-то уже кажется, что не усваивается железо. Тогда вариант с парентеральным введением подходит.

[Mara___dok]

В реальной жизни,я думаю,что начали бы с парентерального введения железа,а потом бы разбирались,если бы не было эффекта через день-два.Но все-таки подходы у нас и "на западе" отличаются.Скорее бы правильные ответы нам рассказали. :)

[dr.Ira]

53. D
54. D
59. A

[брукса]

Перепроверила - правильный ответ Е. Объяснений там нет. Я тоже расценила это, как гематому, но я не знала, что ввиду свежей травмы, их нельзя вскрывать. А почему?Ну.. во-первых я не претендую на истину в последней инстанции...
Если гематома нарастает - по идее если ее вскрыть - можно получить кровотечение.. А на ухе - остановка кровотечения может быть проблематичной.. неудобно там.. ИМХО

[dr.Ira]

О.К. Едем дальше... :)

Items 62-63
A 4-day-old Greek-American neonate is brought to the office because of the development of yellow skin and a rash 1 day after
hospital discharge. She weighed 3400 g (7 lb 8 oz) at birth and is the product of a normal pregnancy. The mother is now gravida 2,
para 2 and she is blood type A, Rh positive. The neonate is blood type O, Rh positive with a negative direct Coombs test. She had
an Apgar score of 8 and 9 at 1 and 5 minutes respectively. The neonate was breast-feeding and was doing well at the time of
discharge. Yesterday, the mother says, the neonate developed about 20 small red spots over her face, trunk and extremities. Today
on physical examination there are many papules that have small vesicles with clear to slightly turbid fluid. Her skin color has
become yellow. The mother says that she continues to feed well. On physical examination the neonate weighs 3250 g (7 lb 2 oz).
There is scleral and skin icterus. No organomegaly or adenopathy is noted. Studies on the neonate show a serum total bilirubin
concentration of 8.7 mg/dL, and concentration of serum conjugated (direct) bilirubin is 0.7 mg/dL.

62. In addition to scheduling a follow-up visit in 1 week, which of the following is the most appropriate advice to give the
mother regarding the icterus?

(A) Ask her to avoid eating foods containing large quantities of carotene
(B) Begin administering small doses of phenobarbital to the neonate
(C) Discontinue breast-feeding until the jaundice has disappeared
(D) Recommend home phototherapy for the neonate
(E) Recommend no change in child care or feeding of the neonate


63. The appropriate steps are taken. You explain to the mother that the neonate's rash is probably erythema toxicum. Which of
the following is the most appropriate management?

(A) 0.5% hydrocortisone cream applied twice a day
(B) Daily wet-to-dry povidone-iodine (Betadine®) soaks with 1×1 gauze pads on each vesicle
(C) Polymyxin ointment applied twice a day
(D) Routine skin care with soap and water
(E) Scrubbing with entsufon cleanser each day firmly enough to unroof the vesicles


Items 64-65
A 10-year-old girl, who has been undergoing treatment for chronic juvenile rheumatoid arthritis for the past 3 years, is brought to
the office because of painful swelling of the right knee. She has had three episodes of painless swelling of her left knee and ankle,
which have subsided spontaneously with rest and aspirin therapy. She has used no medications between episodes. On physical
examination today there is pronounced redness and warmth around the right knee, and a large effusion is present. Attempts at
active and passive motion cause severe pain.

64. Which of the following is the most appropriate step at this time?

(A) Joint aspiration
(B) Serum antinuclear antibody titer
(C) Serum rheumatoid factor assay
(D) Technetium 99m scan
(E) X-ray films of the joint


65. Which of the following new symptoms or findings, if present, would best indicate the need for further diagnostic studies?
(A) Decreased viscosity of joint fluid
(B) Diffuse increase in technetium 99m uptake around the knee on bone scan
(C) Positive Gram stain of joint fluid
(D) Positive serum rheumatoid factor test
(E) Soft-tissue swelling seen on x-ray films

[OrFun]

62-63

1.Думаю ,Е (для фототерапии уровень билирубина должен быть выше 350 мм/л , т.е 20 мг/дл , для пробного прекращения ГВ-12 мг/дл)
2. Д

[dr.Ira]

62. E
63. D
64. A
65. C

[dr.Ira]

Следующие три вопроса:

73. A 4-year-old boy is brought to the office because he has become unmanageable at his day-care center. At previous visits he
exhibited some behavior problems to which his mother did not set limits. He constantly interrupted situations, seeking his
mother's attention. She now reports that during the past few months his fighting, refusal to obey the day-care workers and
violations of "time out" have become much worse. He began to attend day-care at 6 weeks of age so that his mother could
return to work. His father works as a house painter and he is alcohol-dependent. The boy has a 6-month-old sister who also
attends the same day-care center. Records show his height and weight are at the 5th percentile, and his growth velocity is
normal. There were no complications during the pregnancy with this child and he has not had any significant medical
problems. His physical examination today is normal. Which of the following is the most likely cause for this child's
worsening behavior?

(A) Aggressiveness to compensate for a poor self-image caused by short stature
(B) Attention-deficit/hyperactivity disorder
(C) A reaction to his father's drinking
(D) Reduction in his mother's attention because of his new sibling
(E) A toxic reaction to organic fumes from his father's clothes and work materials


88. A 6-month-old Latino infant is brought to the office by his parents because of intermittent swelling in his right scrotum.
They say the swelling is more pronounced when he cries. The swelling has never been red or "stuck." A right inguinal
hernia is confirmed on physical examination. In discussing repair of the hernia with the parents, you should inform them
which of the following?

(A) Herniorrhaphy can be postponed until age 2 years because many hernias close spontaneously
(B) Herniorrhaphy can be postponed until age 12 years because oligospermia does not develop before age 12
(C) Herniorrhaphy should be scheduled at the earliest convenient time
(D) Herniorrhaphy should be scheduled as an emergency
(E) There is no need to repair a hernia in childhood unless incarceration occurs


92. An 8-month-old infant with trisomy 21 (Down syndrome) has a grade 2-3/6 systolic ejection murmur heard best at the left
sternal border, but it can be heard all over the precordium. S2 is split normally and is loud. She has had two episodes of
pneumonia in the past 2 months. Which of the following is the most appropriate next step?

(A) Do a PPD skin test
(B) Initiate an immunologic evaluation
(C) Order sweat chloride test
(D) Presume the murmur is functional and schedule follow-up visits
(E) Seek consultation with a cardiologist

[OrFun]

1.D
2.A
3.E (интересно , а назначить эхо-кг без кардиолога можно ?)
Дааа , больше вопросов у меня , чем ответов ...но тем интересней узнать правильные.

[Mara___dok]

1.B.Все-таки проблемы с поведением были и до появления сестры?
2.С.Пахово-мошоночные грыжи оперируют не дожидаясь 12 лет.
3.Е.

[dr.Ira]

73. - D
88. - C
92. - E

[dr.Ira]

3.E (интересно , а назначить эхо-кг без кардиолога можно ?)

У нас можно. Другое дело, что у нас ЭХО делают детям делают детские кардиологи. Поэтому, давая направление на ЭХО, я знаю, что ребенка будет смотреть кардиолог.

[dr.Ira]

B.Все-таки проблемы с поведением были и до появления сестры?
В 4 года такой (B) Attention-deficit/hyperactivity disorderдиагноз не ставят. :)

[dr.Ira]

Следующие три вопроса. :)

Items 112-113

An obese 10-year-old boy with diabetes mellitus is admitted to the hospital because of severe ketoacidosis and cardiovascular
collapse. Initial management consists of cardiac monitoring and intravenous administration of fluids, electrolytes and insulin.
Because of the difficulty in obtaining satisfactory peripheral venous access, the left femoral vein is catheterized percutaneously. Six
hours later, his mental status is improved, blood pressure is 120/70 mm Hg and serum glucose concentration is 250 mg/dL.
Physical examination at that time shows a cold left foot with diminished pulses compared with those of the right foot.


112. Which of the following is the most likely explanation for this patient's diminished pulses?
(A) Paradoxical embolus from the femoral vein
(B) Diabetic arteriopathy
(C) Inadvertent injury of the femoral artery
(D) Intense arteriolar constriction induced by hyperosmolality
(E) Thrombosis of the catheterized femoral vein

113. A deficit of which of the following electrolytes in this patient is most likely to cause death?
(A) Bicarbonate
(B) Calcium
(C) Chloride
(D) Potassium
(E) Sodium


123. A 15-year-old African-American girl comes to the emergency department because, she says, "something is sticking out of
my bottom since I had a bowel movement this morning." She denies previous episodes, although for more than 1 year she
has had occasional difficulty passing stools. She is not in pain at present, but she is afraid to move her bowels for fear that the
problem will get worse. In response to your questions, she tells you that she moved away from home more than a year ago
and her parents contribute nothing to her support. She has a 6-month-old child and lives with a 28-year-old female cousin.
She has never been married and does not work or attend school. She has no other symptoms. In order to follow the correct
procedure for treating a minor, which of the following is the most appropriate step prior to evaluating this patient's rectal
problem?

(A) Accept the girl's consent as sufficient
(B) Obtain a court order permitting evaluation
(C) Obtain the written consent of at least two licensed physicians
(D) Obtain written consent from at least one of her parents
(E) Obtain written consent from her 28-year-old cousin

[Anna_Shvedova]

112 - А (может быть, С - но тогда был бы напряженный отек?)
113 - D
114 - C (а то пока решения суда дождешься...)

[OrFun]

112-Е (или все-таки А)???
113-Д(этот вариант напрашивается , но данный пациент в кетоацидозе , потому и А тоже нельзя сбрасывать со счетов...)
114-Д
Опять одни вопросы ... Скучать не приходится ;)

[Mara___dok]

112-Е
113-Д Potassium-это Калий,я надеюсь.
114-Д

[dr.Ira]

112. C
113. D
123. A

[dr.Ira]

A healthy 12-year-old boy is brought to the clinic for a sports participation physical examination. He is planning on trying out for the junior varsity football team. He is going into seventh grade and his school recently switched the high school to seventh through twelfth grade. His mother tells you that he is very concerned because he has "not yet reached puberty" and he is afraid that he is going to be "harassed" by the older boys. Physical examination shows no pubic hair and a preadolescent penis and testes. The remainder of the physical examination is unremarkable. The mother and patient want to know "what is going on." At this time you should
A. advise him that he should consider taking male hormones, such as testosterone
B. explain that puberty usually starts by 10 years old and that he is most likely developmentally delayed
C. recommend that he go for genetic testing to evaluate him for a genetic disease
D. tell him that he should be looking for testicular enlargement as the first sign of puberty
E. tell them that everybody is different and there is no particular, predictable pattern of development

[Mara___dok]

Скорее всего Е.

[OrFun]

..Е..

[yananshs]

Е, мне кажется. Остальные ответы какие-то дурацкие.

[dr.Ira]

Explanation:

The correct answer is D. Puberty usually refers to the time between the development of secondary sexual characteristics and rapid growth and the end of somatic growth. It may occur at different times, but often follows a predictable pattern. The first sign of puberty in boys is testicular enlargement, which often occurs at 11.6 years of age. 11-12 years old is the average age of pubertal development in boys. But the normal range is 9-14 years. Therefore, this boy needs reassurance that he is within the normal range and since he is anxiously awaiting puberty, he should be told what to look for as the first sign.

Advising him that he should consider taking male hormones, such as testosterone (choice A) is inappropriate because he is well within the normal range of development at this time. The average age of the onset of puberty is 11-12 years, but the range is from 9-14 years.

It is incorrect to explain that puberty usually starts by 10 years old and that he is most likely developmentally delayed (choice B) because the average age of onset is 11-12 years, but the range is from 9-14 years. It is premature to tell him that he is delayed.

Recommending that he go for genetic testing to evaluate him for a genetic disease (choice C) is incorrect because he is only 12 years old and the normal range for the onset of puberty is 11-12, and the range is 9-14 years. If the remainder of the physical examination is unremarkable, and he has had no previous problems, genetic testing at this time is inappropriate.

Even though development may occur at different ages, there is often a predictable pattern of pubertal development called Tanner stages. It is therefore incorrect to tell them that everybody is different and there is no particular, predictable pattern of development (choice E). In males, stage I refers to a preadolescent with no pubic hair, stage II refers to testicular enlargement and scant pubic hair, stage III refers to penile enlargement, greater testicular enlargement and curling of pubic hair, stage IV refers to greater penile enlargement, darkening of the scrotum, and adult-type pubic hair (but less of it), and stage V refers to adult size penis and testes and adult distribution of pubic hair.

[yananshs]

Но все равно непонятно, зачем мальчику все время туда смотреть?

[dr.Ira]

Думаю, что правильный ответ - Д - именно из-за этой фразы Even though development may occur at different ages, there is often a predictable pattern of pubertal development called Tanner stages.

[dr.Ira]

You are the doctor covering the newborn nursery, when a new baby is brought in from the delivery room. The baby was born full term, there were no complications at the time of delivery, and the baby appears well now. The Apgar scores were 9 at 1 minute and 9 at 5 minutes. You review the mother's prenatal history and discover that she had a vaginal swab positive for group B Streptococcus. Upon further review of the records, you note that the mother received one dose of ampicillin three hours prior to delivery, had rupture of membranes for 5 hours, and did not have a fever. The most appropriate initial management of this baby is
A. close observation only
B. complete blood count with differential
C. complete blood count with differential and blood culture
D. complete blood count with differential, blood culture, and lumbar puncture
E. complete blood count with differential, blood culture, lumbar puncture, and chest x-ray

[riltsov]

Ампицилин дали, мама и ребенок здоровы, по-моему, нужно только - A. close observation only

[Mara___dok]

Скорее всего -А.Только я не понимаю зачем мама ребенка получала ампициллин.

[OrFun]

..А..
насчет ампициллина - а правда , разве сейчас не амоксиклав+метронидазол ? Или путаю с ОКС ?

[riltsov]

Я решительно не понимаю, для чего дали ампициллин, но это информация еще одно подтверждение для варианта - А.

[dr.Ira]

Explanation:

The correct answer is C. According to the guidelines written by the American Academy of Pediatrics in reference to babies born of mothers with group B Strep, if a baby is born at greater than 35 weeks gestation, appears well, but the mother received less than 2 doses of antibiotics (either ampicillin or penicillin) a limited evaluation is indicated. This evaluation includes a CBC, with differential and a blood culture with close clinical observation for at least 48 hours. No antibiotic therapy needs to be started on the baby if all results are normal and the baby continues to appear well.

Close observation only (choice A) would be appropriate for this child only if the mother had received at least 2 doses of antibiotics prior to the delivery. If this had been the case, no laboratory evaluation, and no therapy would be indicated, just close clinical observation for at least 48 hours.

A CBC with differential but no blood culture (choice B) is not a complete work-up for this baby. As stated above, the guidelines indicate that for a baby born to a group B Strep-positive mother who received less than 2 doses of intrapartum antibiotics, both a CBC and blood culture are indicated.

A more complete work-up such as CBC with differential, blood culture, and lumbar puncture (choice D) would be indicated in this baby if there were any signs of sepsis such as prematurity, fever, hypothermia, irritability, or low platelets. If there is a concern of sepsis, after the above tests are done, the baby should be started on empiric antibiotic therapy with ampicillin plus an aminoglycoside or a third-generation cephalosporin. If all the laboratory results and clinical course are unremarkable, and the cultures do not grow, the antibiotic therapy is usually stopped after 48 to 72 hours.

Tachypnea is another sign of sepsis in a neonate. If this baby was tachypneic, a CBC with differential, blood culture, lumbar puncture, and chest x-ray (choice E) would all be indicated. After those tests were completed the baby should be started on empiric antibiotic therapy. If the respiratory distress continues, the baby should be evaluated for possible transfer to the neonatal intensive care unit.

[Alon]

Это стандарная задача, основа работы акушер-гинеколога и неонатолога.
Ответ написан, по-видимому, до выхода последних рекомендации ([Ссылки могут видеть только зарегистрированные и активированные пользователи]) и основан на устаревшем подходе ([Ссылки могут видеть только зарегистрированные и активированные пользователи]).
Хотя верно все-равно "С" :)

[dr.Ira]

A 19-year-old college student comes to the student health service because of a 12-hour history of increased frequency and burning on urination. For the past 6 hours she has felt the need to urinate, but can only produce a "few drops" at each attempt. She is otherwise in good health and had a periodic health maintenance examination just 2 months ago. She does mention that since that check up she has started seeing a new boyfriend and they have recently begun to have intercourse. A urine dip is positive for nitrites. In addition to sending a urine specimen for culture and sensitivity, the most appropriate next step is to
A. advise the patient that she should abstain from sexual intercourse
B. advise the patient that she should drink increased amounts of cranberry juice to help acidify her urine
C. advise the patient that she should empty her bladder both before and after intercourse
D. give the patient a prescription for ampicillin tablets
E. tell the patient to return in 2 days when you will have the preliminary results of the urine culture and its sensitivities

[riltsov]

E. tell the patient to return in 2 days when you will have the preliminary results of the urine culture and its sensitivities

Логично сначала установить природу возбудителя, а потом назначать лечение. Тем более, потому что новый бойфрэнд мог её наградить гонококком.

[Mara___dok]

Ответ Д.

[OrFun]

Children with cystitis usually do not require special medical care other than appropriate antibiotic therapy and symptomatic therapy if the voiding symptoms are marked.
Видимо , Д ? Правда это про маленьких детей .

[yananshs]

Наверное, Д?

[dr.Ira]

The correct answer is D. This patient has classic signs and symptoms of a urinary tract infection (UTI). Symptoms include dysuria, frequency, and urgency. UTIs are common, especially with the onset of sexual relations with a new partner. The most common causes of UTIs include E. coli, Enterococcus, and Proteus. Since the urine dip is positive for nitrites, she should be given a prescription for ampicillin.

It is inappropriate to advise the patient to abstain from sexual intercourse (choice A). Sexual intercourse does not need to be avoided when a patient has a UTI.

Advise the patient that she should drink increased amounts of cranberry juice to help acidify her urine (choice B) and advise the patient that she should empty her bladder both before and after intercourse (choice C) are both suggestions that may be helpful for prevention of future UTIs. However, the patient still needs treatment for her current infection.

UTIs should be treated in order to avoid advancement to pyelonephritis, therefore it is inappropriate to (choice E) tell the patient to return in 2 days when you will have the preliminary results of the urine culture and its sensitivities. If sensitivity returns and the organism is not sensitive to what you prescribe, treatment can be altered.

[yananshs]

A 3-year-old boy is brought to the office because of a 3-day history of fever and vomiting followed by watery diarrhea. The father tells you that the child is very lethargic and seems dehydrated. He attends daycare 5 days a week and 4 other children have had similar symptoms over the past month. The patient appears moderately dehydrated. When you go to examine him you notice that there is a moderate amount of stool spilling out from the sides of the diaper. The father is very embarrassed when he sees this and tells you that he just changed the diaper before coming into the examination room. He is concerned because this "outbreak" has occurred a few other times and he is wondering what can be done to stop the spread of infection. You advise the father to provide plenty of fluids. You should also tell him that:
A. Antiviral therapy is indicated at this time
B. Boiling all drinking water at the daycare center will eliminate future outbreaks of this infection
C. Meticulous laundering of the bedding and clothing of the caregivers and children will stop the spread of infection
D. The patient must be kept home from daycare until his stool can be contained by diapers
E. Vaccination against rotavirus should be given to all of the children and staff at the daycare center

[OrFun]

Наверное , Е :confused: Остальные ответы мне кажутся ...забавными ... ;)

[Mara___dok]

Я не знала,что есть вакцина от ротавирусной инфекции.

[yananshs]

Ответ Е - не подходит.
A recommended, approved vaccine is not currently available in the United States (choice E). A vaccine is available, but it has been associated with cases of intussusception and it is therefore recommended that administration be suspended until further studies are done.
Какие еше варианты?

[Mara___dok]

Я думаю,что ответ В.

[yananshs]

К сожалению, нет.
Boiling all drinking water (choice B) is not helpful because the rotavirus is shed in the stool of infected individuals and is easily spread on contaminated hands and objects. The current recommendation to prevent the spread of rotavirus is careful hand washing. 70% ethanol solution is also recommended to inactivate the rotavirus.

Но правильный ответ к этой задачке будет правильным, наверное, только в США.

[Mara___dok]

Ну мы,по моему,все перебрали.Осталось Д.

[riltsov]

Вариант D., в целом, подходит. Больного ребенка необходимо изолировать от здоровых – это важная часть противоэпидемических мероприятий.
Но! Вспышка в детском саду уже произошла, заболели 5 детей! Путь передачи фекально-оральный, вирус устойчив во внешней среде. Кроме изоляции больных детей необходимо: Meticulous laundering of the bedding and clothing of the caregivers and children will stop the spread of infection

Мой ответ C.!

[dr.Ira]

Я тоже думаю Д.

[dr.Ira]

A 16-year-old boy is admitted to the hospital for pneumonia. The patient reports that over the past 3 days he has had an increasing cough, productive of thick, green sputum and pleuritic chest pain. He has a history of cystic fibrosis and has been hospitalized for pneumonia 9 times in the past 3 years. He has never been intubated, but has required prolonged hospital stays at times in order to manage his infections. His medications include pancreatic enzymes and acetylcysteine nebulizers. The most appropriate management of this patient is to
A. begin aggressive chest physiotherapy
B. give him inhaled beta agonists
C. enroll him in gene therapy trials
D. evaluate him for lung transplantation
E. obtain a sputum culture and await results for directed antibiotic therapy

[Mara___dok]

cystic fibrosis - это муковисцидоз?Если это так
то я выбираю сначала в2-адреномиметики(ответ В)

[Nancy]

Думаю, вначале В. А потом D.

[Dr.KoMet]

Прошу сразу не банить... :)
Я бы выбрал "Е"

Антибиотикам он не лечился, а госпитализируется часто.

[Mara___dok]

Антибиотикам он не лечился, а госпитализируется часто.
Имеется ввиду,что вне обострения пневмонии,он получает ферменты и муколитики,а при обострении получает антибиотик.Я выбрала В,в смысле последовательности действий.Затем скорее всего идет Е.
А насчет пересадки легкого.Не знаю,делают ли ее при муковисцидозе.Есть ли в этом смысл.Хотя я еще так и не уверена,что речь идет именно о нем. :)

[Nancy]

Речь именно о муковисцидозе. А пересадки делают, по-моему(не уверена). 9 раз за 3 года госпитализация по поводу пневмоний - это достаточно много, чтобы думать о трансплантации.

[dr.Ira]

cystic fibrosis - это муковисцидоз.

[Mara___dok]

Ира,а можно еще подсказку?
aggressive chest physiotherapy - что под этим подразумевается?Массаж и постуральный дренаж?Если да,то возможно именно это надо проводить в первую очередь.

[dr.Ira]

The correct answer is A. Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.

Inhaled beta agonists (choice B) offer no benefit for these patients since they have no element of bronchoconstriction to their disease. All of the airway issues in these patients relates to the thick mucous plugs that they are unable to clear.

Despite some of the early successes in gene therapy for CF, early enrollment in gene therapy trials (choice C) is still not considered a standard of care and does not replace in any way the most basic management principles of caring for patients with CF which is antibiotics and chest physical therapy.

It is appropriate to begin evaluation for lung transplantation (choice D) at any time during the course of CF. However, such an evaluation does not in any way assist in managing the acute infection that the patient is currently suffering.
Most patients with CF have defined pathogenic flora such as pseudomonas. For this reason, a sputum culture for directed antibiotic therapy (choice E) to direct therapy is not critical and antibiotic coverage can be initiated prior to any definitive culture data being returned.

[dr.Ira]

You are asked to see a baby in the newborn nursery. The baby is small for gestational age and has microcephaly. Physical examination shows hepatomegaly, a widened pulse pressure, a "machinery" heart murmur, and a purpuric skin rash. There is no red reflex in either eye. At this point, you are suspicious that the baby has a congenital infection caused by
A. Cytomegalovirus
B. rubella virus
C. Toxoplasma gondii
D. Treponema pallidum
E. varicella-zoster virus

[Mara___dok]

Скорее все же краснуха.

[dr.Ira]

The correct answer is B. This baby most likely has congenital rubella. Some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a "blueberry muffin" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect.

Congenital Cytomegalovirus (CMV) infection (choice A) is usually asymptomatic at birth (approximately 85% of the time). Clinical manifestation is found to be severe in approximately 5% of babies with congenital CMV. Manifestations include: intrauterine growth retardation, chorioretinitis, microcephaly, intracerebral calcifications, hepatosplenomegaly, jaundice, thrombocytopenia, neutropenia, purpura, and pneumonia. Although the baby in the question has many of the defects found in congenital CMV, congential heart defects and cataracts are not associated with CMV.

Toxoplasma gondii(choice C) is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth will develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash.

Treponema pallidum(choice D) is the organism responsible for syphilis infection. Congenital syphilis is characterized by nonimmune hydrops, prematurity, anemia, neutropenia, thrombocytopenia, pneumonia, and hepatomegaly. Late onset syphilis, which may present up to two years of age, is characterized by snuffles, rash, hepatosplenomegaly, condylomata lata, osteochondritis, cerebrospinal fluid pleocytosis, lymphadenopathy, and thrombocytopenia. Untreated infants may develop late manifestations involving the central nervous system, teeth, eyes, skin, ears, bones, and joints.

Varicella-zoster infection (choice E) in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death.

[yananshs]

[Ссылки могут видеть только зарегистрированные и активированные пользователи]
A 7-year-old girl is admitted to the hospital because of a 3-week history of fever, leukopenia, nausea, abdominal pain, and arm weakness. The patient had undergone a workup for infection at an outside facility prior to admission and was given a 5-day course of doxycycline to treat a fever of unknown cause. On this presentation, a peripheral blood smear is obtained and shows numerous leukoblasts. Subsequent bone marrow biopsy reveals acute lymphoblastic leukemia (ALL). Induction therapy, which includes dexamethasone, vincristine, pegylated (PEG)-asparaginase, and intrathecal methotrexate, is initiated.

Nine days after therapy begins, the patient has 2 tender, slightly raised, and erythematous lesions on her right arm. Her WBC count is 1.81 X 10/L (1810/µL) cm2 with a platelet count of 39 X 109/L (39 X 10/µL). The next morning, the largest lesion, which measures 15 mm, has a 5-mm darkened center. The lesions progress, and, by the next day, measure 20 mm with a 10-mm central area with dark discoloration (see Image 1).

Cefepime is administered for a suspected diagnosis of ecthyma gangrenosum, and fluconazole as prophylactic therapy is continued. Despite treatment with the antimicrobials, the lesion continues to grow and becomes increasingly tender to palpation, with progression to small surrounding satellite areas.

The patient is taken to an operating room, where the lesions are widely resected and samples are obtained to be sent to pathology and microbiology for examination. In addition to the tissue undergoing standard Gram staining and aerobic and anaerobic culture, acid-fast staining, mycobacterial culture, fungal staining, and viral culture are also performed.

Histopathology of the resected specimen reveals a 2.6 X 1.5 X 0.8-cm ellipse of skin that contains several lesions. The largest lesion is 1.0 X 1.3 cm and has a 1- to 2-mm rim of erythema around its dark center. About 4 mm from the largest lesion, a second lesion measures 3 X 2 mm and has surrounding erythema. The epidermis is laterally intact but centrally affected by ischemic necrosis (see Image 2). The dermis and subcutaneous tissues contain an extensive infiltrate of fungal hyphal elements involving the walls of the blood vessels, surrounding tissues, and focal perineural areas (see Image 3). Fungal elements are noted within 1 mm of each lateral resection margin (see Image 4).

What was the diagnosis?

[Dr.]

Актиномикоз :)

[dr.Ira]

Aspergillosis (M.p. :) )
Few or many lesions
May result in rapidly spreading red patch with a necrotic centre (blackened dead tissue)
May resemble pyoderma gangrenosum

Patients who
are at considerable risk include
those who are granulocytopenic
due to bone marrow transplantation,
those who are undergoing
intensive cytotoxic chemotherapy
for the treatment of neoplasia, and
those with a history of corticosteroid
use.

[yananshs]

Answer
Cutaneous zygomycosis: The wound biopsy cultures grew out Rhizopus species, a fungus in the Mucorales order. Because of this finding, in conjunction with the findings on histopathology, dermatomycosis, specifically cutaneous zygomycosis, was diagnosed. Zygomycosis is an uncommon and potentially fatal infection caused by fungi of the class Zygomycetes. The incidence of zygomycosis is increased among immunocompromised patients (Gonzalez, 2002; Roden, 2005). The class Zygomycetes includes 2 orders of pathogens: Mucorales, which is responsible for most cases of human disease, and Entomophthorales (Gonzalez, 2002). Entomophthorales-related disease classically occurs in only tropical and subtropical areas, where it causes a mild form of disease limited to the nasal, sinus, and subcutaneous tissues. However, the geographic distribution and clinical characteristics of disease have increasingly broadened. Because the features of disease caused by Mucorales and Entomophthorales are nearly identical both clinically and histologically, the term mucormycosis is taxonomically inaccurate but nevertheless accepted in the medical terminology (Gonzalez, 2002).

Risk factors for zygomycosis include organ transplantation, malignancy, diabetes, corticosteroid therapy, neutropenia, desferoxamine therapy, HIV infection, metabolic acidosis, burns, and traumatic inoculation (Kontoyiannis, 2000; Dromer, 2002; Gonzalez, 2002; Greenberg, 2004; Roden, 2005). Patients with ketoacidosis are at particular risk for zygomycosis because the acidic environment appears to hinder neutrophil function (Gonzalez, 2002).

This patient had several of these risk factors, including ALL, hyperglycemia secondary to corticosteroid therapy, and neutropenia. Because neutrophils are the predominant mediators of the host defense's against fungal hyphae, the patient's state of neutropenia gave rise to invasive disease. Leukemia is the underlying risk factor in 15% of patients with zygomycotic infections (Dromer, 2002). This patient developed a cutaneous infection, which is generally less severe than rhinocerebral or pulmonary infection, but it may indicate disseminated infection (Gonzalez, 2002; Sundararajan, 2004). The incidence of disseminated infection is highest in patients with a hematologic malignancy (Dromer, 2002). Thorough examination and imaging studies should be performed to rule out disseminated infection (Gonzalez, 2002; Roden, 2005). Tissue biopsy and cultures are necessary to diagnose zygomycotic infection (Dromer, 2002; Gonzalez, 2002).

The management of zygomycosis starts with a high index of suspicion in appropriate populations, early diagnosis, and aggressive therapy (Dromer, 2002; Gonzalez, 2002). The most effective therapy is a combination of surgical debridement; high-dose amphotericin-B; and treatment of underlying conditions, such as neutropenia or hyperglycemia (Kontoyiannis, 2000; Dromer, 2002; Gonzalez, 2002; Pagano, 2004). Liposomal amphotericin-B continues to be the drug of choice, even though new antifungal agents have emerged (Kontoyiannis, 2000; Gonzalez, 2002; Pagano, 2004; Roden, 2005). No therapy prevents this infection (Kontoyiannis, 2000; Dromer, 2002; Gonzalez, 2002; Pagano, 2004).

In our case, liposomal amphotericin B at 5 mg/kg was started empirically shortly before the histopathologic diagnosis on clinical suspicion and was continued along with daily wet-to-dry dressings for general wound care. Computed tomography scans of the head, chest, abdomen, and pelvis were performed to evaluate for potential disseminated disease and were negative. Additionally, an ophthalmologic examination was performed and was unremarkable. After 6 days of therapy, the area around the excision site darkened and a repeat debridement and biopsy of the previous margins failed to reveal any fungal elements. The patient received liposomal amphotericin B for a total of 6 weeks with weekly monitoring of electrolyte levels. After treatment was completed, a skin graft was performed on the affected areas of her right forearm which took well and healed without complication.
[Ссылки могут видеть только зарегистрированные и активированные пользователи]

[Timur]

4-х месячный ребёнок доставлен в пункт неотложной помощи (ER) с высокой температурой и общим беспокойством. Выполнена люмбальная пункция: в ликворе 10 эритроцитов и 1050 лейкоцитов, 50 мг% (0,5 г/л) белка, 40 мг% (2,26 ммоль/л) глюкозы. При окраске по Граму осадка ликвора бактерии не обнаружены. Адекватным лечением больного следует считать:
(A) наблюдение в стационаре без проведения антибиотикотерапии
(B) внутривенное введение ампициллина и гентамицина
(C) внутривенное введение цефтриаксона
(B) внутривенное введение оксациллина и гентамицина
(E) внктривенное введение ампициллина

PS: Если есть желание, то в дальнейшем опубликую "ещё парочку" (с)

[dr.Ira]

1) Approximately 2-3% of bacterial meningitis cases have a negative Gram stain result and normal cell count, glucose level, and protein level yet positive bacterial cultures.
2) Хотелось бы также отметить, что важно не просто содержание глюкозы в ликворе, а ее соотношение с глюкозой крови. За бактериальный менингит , когда содержание глюкозы в ликворе составляет менее 50% от глюкозы в крови.
3) С нормами вашими я совсем запуталась :) , не могу перевести г/л в мг/dl, но, хотя, лейкоцитов для бактериального менингита явно не хватает (должно быть больше 2000), я, помня о пункте 1,
предлагаю вариант с цефтриаксоном до получения отрицательного посева.

[qwerty]

А высокая температура и "общее беспокойство" у детей достаточны для подозрения на менингит? Про менингеальные симптомы ничего не сказано. Я бы выбрала вариант а.

[yananshs]

Мне кажется, задача не имеет решения. Показания для люмбарной пунkции неизвестны. Нет результата осмотра. Нет крови.

[Dr.]

У меня в анналах есть похожая задачка, сейчас гляну :)

[Timur]

А высокая температура и "общее беспокойство" у детей достаточны для подозрения на менингит? Про менингеальные симптомы ничего не сказано.
Из ответа к задаче - "Болезнь может начинаться с проявления неспецифических симптомов, таких как раздражительность и лихорадка. Исследование СМЖ позволяет выявить повышенное содержание в ней лейкоцитов и белка. Уровень глюкозы снижается. Посев ликвора и окраска по Граму его осадка не всегда дают положительные результаты по выявлению возбудителя." У ребёнка бактериальный менингит. Как правило, промедление - смерти подобно.
Какие ещё будут мнения по терапии?
ЗЫ: 1мг/дл=1мг% (про цент, то есть в ста)

[yananshs]

Bacterial meningitisClinical history.

-The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
-The child younger than 3 months may have very nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high pitched cry, or seizures.
-Meningismus and a bulging fontanel may be observed but are not needed for diagnosis.
-A child who is quiet at rest but who cries when moved or comforted may have meningeal irritation (paradoxical irritability).
-After age 3 months, the child may display symptoms more often associated with bacterial meningitis, with fever, vomiting, irritability, lethargy, or any change in behavior.
-After age 2-3 years, children may complain of headache, stiff neck, and photophobia.


Bacterial meningitisLabs.

-White blood cell (WBC) counts over 1000/mm3 usually are caused by bacterial infections. Counts of 500-1000/mm3 may be bacterial or viral and need further evaluation. Lower counts are usually associated with viral infections. The total WBC count cannot definitely distinguish between bacterial and other causes. It was generally believed that a predominance of polymorphonucleocytes (PMNs) pointed to bacterial meningitis, but this has been unreliable.
-Gram stain may aid in diagnosis, but the diagnosis may be missed in up to 30% of cases of culture-proven disease.
-The protein concentration usually is elevated in bacterial meningitis, but it also is elevated by a traumatic tap.
-The glucose is usually reduced in bacterial meningitis. Normal CSF glucose should be greater than two-thirds that of the serum glucose. Levels less than 50% of serum are suggestive of bacterial meningitis.
-Latex agglutination tests are available to test for S pneumoniae, H influenzae, group B Streptococcus, and N meningitidis. A negative result, however, does not rule out bacterial infection.
-Even with normal CSF results, the fluid should be sent for culture. N meningitidis and S pneumoniae are known to give normal CSF results.


Emergency Department Care:

Immediate stabilization and support of the critically ill or seizing child is necessary.
When meningitis or encephalitis is suspected, an LP is indicated.
If the child's condition is unstable or there is suspicion of increased intracranial pressure, the LP should be delayed.
It is very important that antibiotic therapy is immediately commenced in the ill child and not delayed until after the LP.
If prompt LP cannot be performed, administration of antibiotics should be initiated. However, sterilization of CSF will occur. It was previously thought that sterilization occurs within 2-3 hours. However, in a retrospective study, complete sterilization was found to occur within 2 hours for meningococcal meningitis. With pneumonococcal infections, sterilization occurred within 4 hours.
If the child is hemodynamically stable, intravenous fluids should be administered at maintenance. Careful record of the patient's weight, urine specific gravity, and serum osmolarity will help guide further fluid therapy. Patients who present with dehydration need rehydration and should not have fluid restriction. Seizures should be treated promptly and should be expected at any time during the initial management.

Empiric antimicrobial therapy for bacterial meningitis:

[Ссылки могут видеть только зарегистрированные и активированные пользователи].1

[yananshs]

Видимо, авторы подразумевают ответ В. внутривенное введение ампициллина и гентамицина. Хотя, если ребёнку больше 3 месяцев, его вроде бы должны лечить ампициллином и хлорамфениколом.

[Nancy]

Видимо, В все-таки...

[yananshs]

Тимур, ау!

[Timur]

Тимур, ау!
Тута я :) .
Ирина правильно ответила, просто было интересно, какие ещё будут предложения.
Продолжение из ответа:"У детей грудного и старшего возраста чаще всего бактериальный менингит вызывают Haemophilus influenzae типа В, Streptococcus pneumoniae и Neiseria menugitidis. С учётом этого антибиотикотерапия включает цефалоспорины третьего покления: цефотаксим, цефтриаксон или ампициллин с левомицетином".

[yananshs]

Но это же неправильный ответ.

[Timur]

Но это же неправильный ответ.
Почему не правильный? Яна, по вашей же ссылке именно так и выходит:

"Immunocompetent children: age > 3 months - 18 years


H. influenzae

S. pneumoniae

N. meningitidis
Cefotaxime or ceftriaxone**
Ampicillin plus chloramphenicol"

[Timur]

Двухлетняя девочка доставлена в кабинет неотложной помощи (ER). За 10 минут до этого во время еды подавилась сосиской. У неё приступообразный кашель; появилась осиплость голоса. В кабинете Н П в первую очередь следует:
(A) ввести пальцы в рот ребёнка, установить локализацию инородного тела и извлечь его
(B) нанести пять энергичных толчков по спине, после чего пять раз энергично надавить на грудь
(С) нанести три толчка в живот (приём Хаймлиха)
(D) убедиться в наличии признаков жизни и оценить адекватность самостоятельного дыхания
(E) сделать рентгеновские снимки грудной клетки и шеи.

[yananshs]

Почему не правильный?
Immunocompetent children: age > 3 months
Developed countries - Cefotaxime or ceftriaxone
Developing countries - Ampicillin plus chloramphenicol

[Ссылки могут видеть только зарегистрированные и активированные пользователи].1

А Россия относится к developed countries or developing countries? Ира для Израиля ответила.

[Timur]

Immunocompetent children: age > 3 months
Developed countries - Cefotaxime or ceftriaxone
Developing countries - Ampicillin plus chloramphenicol

[Ссылки могут видеть только зарегистрированные и активированные пользователи].1

А Россия относится к developed countries or developing countries? Ира для Израиля ответила.
Яна, во-первых - то, что Россия относится к развивающимся странам, вопрос дискутабельный и не будем в этом разделе его развивать (очень прошу), а во-вторых - почитайте внимательнее - Developing countries - Ampicillin plus chloramphenicol (хлорамфеникол есть ни что иное, как левомицетин). В-третьих - задача из тестовых экзаменов, и приведён оптимальный вариант, а именно цефтриаксон.
PS: Яне, большое спасибо за очень хорошую ссылку.

[yananshs]

OK, if you say so. :)

[OrFun]

Наверное D ? Из условия четкого суждения о vital signs вынести нельзя...

[yananshs]

По-моему, если ребёнок кашляет и говорит (осиплость голоса), то надо дать ему дальше кашлять. Главное не давать пить. По спине нельзя стучать. Если сосиска торчит, то можно выташить, наверное. Главное, не засунуть эту сосиску дальше. Приём Хаймлиха делают, если не дышит, насколько я помню.

[OrFun]

Для проведения приема Хаймлиха , девочка , по-моему ,мала...Если ребенок действительно в сознании и говорит (хотя из условия задачи это и не очевидно) тогда ,видимо В ?

[yananshs]

По идее детям после одного года делают прием Хаймлиха. Может в России иначе.
По спине же нельзя колотить. :confused:

[dr.Ira]

(A) ввести пальцы в рот ребёнка, установить локализацию инородного тела и извлечь его
(B) нанести пять энергичных толчков по спине, после чего пять раз энергично надавить на грудь
(С) нанести три толчка в живот (приём Хаймлиха)
(D) убедиться в наличии признаков жизни и оценить адекватность самостоятельного дыхания
(E) сделать рентгеновские снимки грудной клетки и шеи.
Если следовать формальной логике :) , то любую реанимацию начинают с оценки состояния. Поэтому - Д.
Хаймлих можно делать в любом возрасте. Просто, техника Хаймлих отличается у детей до года.

[Mara___dok]

Все-таки пока ребенок кашляет Хаймлих не проводится.Значит Е.

[Dr.Nathalie]

Однозначно, D в первую очередь, согласна с Ирой.

[Timur]

"У ребёнка, находящегося в сознании и имеющего спонтанный кашель при аспирации инородного тела, недопустимы попытки его удаления. Необходим быстрый осмотр больного с оценкой полноты функционирования важных органов. После этого целесообразно проведение рентгенографии органов шеи и грудной клетки. Как указывалось выше, введение пальцев в рот ребёнка для удаления инородного тела опасно, поскольку может способствовать его вклинению в дыхательные пути. У детей первого года жизни приём Хаймлиха не выполняют."

[dr.Ira]

У детей первого года жизни приём Хаймлиха не выполняют."
Это не совсем так. :)
The Heimlich maneuver is an emergency procedure for removing a foreign object lodged in the airway that is preventing a person from breathing
...........


CHILDREN

The technique in children over one year of age is the same as in adults, except that the amount of force used is less than that used with adults in order to avoid damaging the child's ribs, breastbone, and internal organs.

INFANTS UNDER ONE YEAR OLD

The rescuer sits down and lays the infant along his or her forearm with the infant's face pointed toward the floor. The rescuer's hand supports the infant's head, and his or her forearm rests on his or her own thigh for additional support. Using the heel of the other hand, the rescuer administers four or five rapid blows to the infant's back between the shoulder blades.

After administering the back blows, the rescuer sandwiches the infant between his or her arms, and turns the infant over so that the infant is lying face up supported by the opposite arm. Using the free hand, the rescuer places the index and middle finger on the center of the breastbone and makes four sharp chest thrusts. This series of back blows and chest thrusts is alternated until the foreign object is expelled.
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[yananshs]

В США прием, который детям делают до одного года, обычно не называют приемом Хаймлиха. Видимо, чтобы не запутать оказываюших помошь.

[Timur]

Это не совсем так. :)
Пусть, не совсем так, но опасно в неопытных руках и можно повредить внутренние органы. Не рекомендовал бы к повсеместному применению.
So, the next situation:
Через два часа после введения вакцины АКДС у четырёхмесяцного мальчика поднялась температура до 38,3, появилось общее беспокойство. Какова тактика врача при осмотре пациента в 6-ти месячном возрасте?
(A) Отложить вакцинацию против коклЮша и ввести столбнячный и дифтерийный анатоксины
(B) Отложить вакцинацию против коклЮша и ввести столбнячный и дифтерийный анатоксины в сниженной дозировке
(С) Ввести половину обычной дозы вакцины АКДС
(D) Отложить все прививки до 12-ти месяячного возраста
(E) Ввести вакцину АКДС, рекомендовав превентивное лечение с целью предупреждения гипертермической реакции

[yananshs]

Пусть, не совсем так, но опасно в неопытных руках и можно повредить внутренние органы. Не рекомендовал бы к повсеместному применению.
Если кто-нибудь прислушается к вашей рекомендации, то смертность среди детей до одного года возрастет.


Treatment for Infants
Your aims are to remove the obstruction and to arrange urgent removal to hospital if necessary.
If the infant is distressed, is unable to cry cough, or breathe:
Lay them face down along your forearm, with their head low, and support the back and head.
Give up to 5 Back Blows, with the heel of your hand.
Check the infant's mouth; remove any obvious obstructions.
Do not do a finger sweep of the mouth.
If the obstruction is still present:
Turn the infant onto his back and give up to 5 Chest Thrusts
Use two fingers, push inwards and upwards (towards the head) against the infants breastbone, one finger's breadth below the nipple line.
The aim is to relieve the obstruction with each chest thrust rather than necessarily doing all five.
Check the mouth
If the obstruction does not clear after three cycles of back blows and chest thrusts:
Dial 03 for an ambulance
Continue until help arrives

[Timur]

Если кто-нибудь прислушается к вашей рекомендации, то смертность среди детей до одного года возрастет.
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"С другой стороны, стоит заметить, что такое описание вряд ли поможет Вам при отсутствии опыта. Вы можете выучить его наизусть, но при этом не освоите сам навык."

[yananshs]

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[Timur]

[Ссылки могут видеть только зарегистрированные и активированные пользователи]
-If the victim can speak, cough, or breathe, DO NOT INTERFERE.
Яна - это из вашей же ссылки (кстати, опять очень красивой)
А это из условий задачи:
"У неё приступообразный кашель; появилась осиплость голоса."
Вы великолепная спорщица, но это не тот случай ;) .
Не применять метод Хаймлиха детям первого года жизни - это не рекомендация, а правило.
ЗЫ: После Вашего заключения о том, что детская смертность возрастёт если кто-нибудь прислушается к моей рекомендации (заметьте - это не моя рекомендация, а ведущих анестезиологов-реаниматологов, в том числе и самого Хаймлиха) мне стало как-то не посебе :( .
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«CHILDREN

The technique in children over one year of age is the same as in adults, except that the amount of force used is less than that used with adults in order to avoid damaging the child's ribs, breastbone, and internal organs.

INFANTS UNDER ONE YEAR OLD

The rescuer sits down and lays the infant along his or her forearm with the infant's face pointed toward the floor. The rescuer's hand supports the infant's head, and his or her forearm rests on his or her own thigh for additional support. Using the heel of the other hand, the rescuer administers four or five rapid blows to the infant's back between the shoulder blades.»
Резюме - детям до года не производят три толчка в живот, а стучат по спине между лопатками.

[OrFun]

..Е..

[yananshs]

-If the victim can speak, cough, or breathe, DO NOT INTERFERE.
Яна - это из вашей же ссылки (кстати, опять очень красивой)
А это из условий задачи:
"У неё приступообразный кашель; появилась осиплость голоса."
Вы великолепная спорщица, но это не тот случай ;) .
По-моему, если ребёнок кашляет и говорит (осиплость голоса), то надо дать ему дальше кашлять. Главное не давать пить. По спине нельзя стучать. Приём Хаймлиха делают, если не дышит, насколько я помню.
:) :) Of course not.

[Timur]

Напомню условия задачи:
Через два часа после введения вакцины АКДС у четырёхмесяцного мальчика поднялась температура до 38,3, появилось общее беспокойство. Какова тактика врача при осмотре пациента в 6-ти месячном возрасте?
(A) Отложить вакцинацию против коклЮша и ввести столбнячный и дифтерийный анатоксины
(B) Отложить вакцинацию против коклЮша и ввести столбнячный и дифтерийный анатоксины в сниженной дозировке
(С) Ввести половину обычной дозы вакцины АКДС
(D) Отложить все прививки до 12-ти месяячного возраста
(E) Ввести вакцину АКДС, рекомендовав превентивное лечение с целью предупреждения гипертермической реакции

Все увлеклись спором в Ординаторской :cool: .
OrFun, ака Светлана Олеговна, дала правильный ответ - "Е".
"Незначительную температурную реакцию и кратковременное беспокойство расценивают, как слабую реакцию на введение вакцины, такая реакция не является противопоказанием к повторному введению препарата. Необходимо помнить, что введение вакцины должно вызывать развитие ответной реакции в организме (для того она и вводится), и индивидуальные внешние проявления её вполне возможны (в т. ч. незначительное повышение температуры, недомогание и т. п.). Поэтому сразу же прекращать начатый курс активной профилактики при появлении подобной симптоматики не стоит. Реактогенность коклЮшно-дифтерийно-столбнячной вакцины связана с коклЮшным Аг, входящим в её состав. Дифтерийно-столбнячный анатоксин малореактогенен и потому может быть использован при последующей вакцинации и ревакцинации детей, имевших повышенную реакцию на ранее введённую вакцину АКДС. Применительно к данной задаче её можно решить следующим образом: через 1,5 месяца после первой прививки ввести анатоксин и считать вакцинацию законченной, ревакцинацию проводить в календарные сроки."
ЗЫ: Следующую задачу опубликую чуть позже, когда улягутся страсти.

[Tim Vetrov]

Мне кажется, среди перечисленных вариантов правильного ответа нет.
У ребенка была реакция на АКДС средней тяжести. Это не является противопоказанием к продолжению курса вакцинации. Если после второй вакцинации АКДС поднимется температура, можно дать жаропонижающие (парацетамол или ибупрофен) в возрастной дозировке.
Никакого превентивного лечения не требуется. Что вообще понимать под превентивным лечением? Насколько я знаю, превентивное лечение - это назначение этиотропной терапии в предполагаемом инкубационном периоде для профилактики заболевания. Например, доксициклин после укуса клеща.

[Delsol]

A 2-month-old boy is brought to the office for a routine well-baby visit. The mother tells you that he is doing very well, that he drinks 5 oz of formula every 4 hours, stools twice a day, and sleeps 6 hours at a time. His temperature is 37.0 C (98.6 F). Physical examination is normal and he is growing along the 50th percentile for height and weight. After addressing all of the mothers questions and concerns, the most appropriate next step in management is to
A. administer the DTaP, haemophilus-hepatitis B, inactivated polio, and pneumococcal “conjugate” vaccines
B. obtain a bagged urine specimen to check for reducing substances
C. order a complete blood count to evaluate for anemia
D. send the patient home with his mother for a return visit in 2 months
E. send the patient home with his mother and schedule a return visit in 3 weeks

[Delsol]

Somebody? Anybody? ... :(

[Anna_Shvedova]

Не помню сроков (пока незачем их уточнять :), но думаю, что пора прививать малыша.
А.

[Light]

Если следовать российскому графику прививок, то, наверное, Е.

[Mara___dok]

Вариант А.
Но по нашему графику действительно Е.

[Delsol]

Подождем авторитетноe мнениe модераторов раздела "Педиатрия".

[antibiotik]

По "их" графику прививок - вариант А. Задача же "оттуда"

[Delsol]

The correct answer is A. The 2-month visit is the visit of first vaccines. The initial vaccines are DTaP, Hib-Hep B, IPV, and pneumococcal vaccines.

A bagged urine specimen (choice B) is not routinely obtained.

A complete blood count (choice C) is usually done at about the 9 month visit, not at 2 months.

After the initial set of vaccines, the patient may be sent home with a follow up in 2 months. Without the vaccines, it is inappropriate management to send him home for a return visit in 2 months (choice D) or with a return visit in 3 weeks (choice E).

[Delsol]

A 3-year-old boy is brought to the office because of a 2-day history of fever, nausea, weakness, and "yellow skin." He has always been a healthy child, rarely having more that a sore throat or ear infection. The family has not traveled recently and no other family members are sick. A couple of children in his childcare center are sick and a parent of one of the other children has similar symptoms. His temperature is 38.1 C (100.6 F). Physical examination shows icteric skin and conjunctiva but is otherwise unremarkable. Laboratory studies show:

IgM Anti-HAV Positive
HbsAg Negative
HCV-Ag Negative

You should advise the mother that:
A. Hepatitis vaccination that is routinely recommended for all children in the United States would have prevented this illness
B. Her son can return to childcare 5 days after the onset of symptoms
C. Household contacts should receive immune globulin within 2 weeks after last exposure
D. It is likely that her child was sexually abused by his friend's father
E. There is a 30% chance that her son will develop chronic hepatitis

[AlexGold]

The correct answer is A. The 2-month visit is the visit of first vaccines. The initial vaccines are DTaP, Hib-Hep B, IPV, and pneumococcal vaccines. Теперь еще плюс 1-я доза вакцины против ротавирусной инфекции.

[Tim Vetrov]

A 3-year-old boy is brought to the office because of a 2-day history of fever, nausea, weakness, and "yellow skin." He has always been a healthy child, rarely having more that a sore throat or ear infection. The family has not traveled recently and no other family members are sick. A couple of children in his childcare center are sick and a parent of one of the other children has similar symptoms. His temperature is 38.1 C (100.6 F). Physical examination shows icteric skin and conjunctiva but is otherwise unremarkable. Laboratory studies show:

IgM Anti-HAV Positive
HbsAg Negative
HCV-Ag Negative

You should advise the mother that:
A. Hepatitis vaccination that is routinely recommended for all children in the United States would have prevented this illness
B. Her son can return to childcare 5 days after the onset of symptoms
C. Household contacts should receive immune globulin within 2 weeks after last exposure
D. It is likely that her child was sexually abused by his friend's father
E. There is a 30% chance that her son will develop chronic hepatitis

Стойкое ощущение дежа-вю...
Задача [Ссылки могут видеть только зарегистрированные и активированные пользователи]
Мой ответ [Ссылки могут видеть только зарегистрированные и активированные пользователи]
Правильный ответ [Ссылки могут видеть только зарегистрированные и активированные пользователи]
Но все же [Ссылки могут видеть только зарегистрированные и активированные пользователи]
Так что правильный ответ, ИМХО, слегка устарел.

[Delsol]

Вы не один на этом форуме. :). Но - хозяин-барин.
Решайте другую задачу.

[Delsol]

A 17-year-old girl comes to the office for a follow-up visit after being diagnosed with iron deficiency anemia. She has been patient of yours since birth and has always been very healthy. At the last visit, which was 6 weeks ago, she complained of fatigue and she had pale skin and mucus membranes. She is sexually active with one partner and they use condoms for contraception. Initial laboratory studies showed:

Hemoglobin 9.5 g/dL
Hematocrit 30%
Ferritin 5 ng/ml

You advised her to begin taking ferrous sulfate and to eat a well balanced, iron-containing diet with meat. The results of her laboratory studies today show that she is responding to therapy. The most appropriate next step is to
A. advise her to consider oral contraceptive pills to decrease her menstrual blood loss
B. check the mean corpuscular hemoglobin (MCV) and red cell distribution width (RDW)
C. discontinue the ferrous sulfate, but tell her to continue to eat a well-balanced, iron containing diet
D. do a colonoscopy to check for a source of blood loss
E. make no changes in her current treatment plan

[riltsov]

C учетом этого: She is sexually active with one partner and they use condoms for contraception.
Можно рекомендовать это: A. advise her to consider oral contraceptive pills to decrease her menstrual blood loss.

[Tim Vetrov]

Вы не один на этом форуме.
Это я понимаю. Не понятно, зачем повторять задачи из этого же топика?

[Delsol]

Потому что есть новые врачи. И потому что можно забыть, что какую-то задачу уже давал.

[Anna_Shvedova]

Я тоже за А.

[OrFun]

Е.
По-моему железодефицит лечится не менее 8 недель . в данном случае есть ответ на терапию этим приепаратом , значит , пусть дальше его и получает . :p

[Delsol]

The correct answer is E. This patient most likely has iron deficiency anemia because she had a low hemoglobin and hematocrit that is responding to ferrous sulfate therapy and an iron-containing diet. A poor diet and heavy menstrual bleeding are the most likely cause of iron deficiency anemia in a woman of childbearing age. Therapy with ferrous sulfate should be continued for 2-3 more months.

The best next step is to have her continue her current treatment plan, not to advise her to consider oral contraceptive pills to decrease her menstrual blood loss (choice A). The history does not tell you that she has very heavy menstrual bleeding, and even though she has sexual intercourse with one partner, you would first need to discuss this a lot more before advising her to use OCPs. The treatment for iron deficiency anemia is ferrous sulfate and increased dietary intake of iron, not OCPs. OCPs may prevent anemia, but they do not treat it.

The Centers for Disease Control and Prevention recommend that you check the mean corpuscular hemoglobin (MCV) and red cell distribution width (RDW) (choice B) if the anemia does not respond to ferrous sulfate and you are sure that the patient is compliant. Since she is responding to therapy, this is not necessary at this time.

It is incorrect for her to discontinue the ferrous sulfate but, telling her to continue to eat a well-balanced, iron containing diet (choice C) because even though she is responding to therapy, it is recommended that she continue for 2-3 more months on ferrous sulfate to replenish iron stores.

A colonoscopy to check for a source of blood loss (choice D) is not necessary at this time in this patient with iron deficiency anemia that is responding to therapy. The most likely cause of iron deficiency in this patient is heavy menstrual bleeding and possibly a poor diet. If this patient was a postmenopausal woman or a man with iron deficiency anemia, you must think of a gastrointestinal bleed as the cause of anemia. Fecal occult blood testing and a colonoscopy should be considered for these other patients.

[dr.Ira]

Давно мы что-то пилюлек не принимали...:ag:
Вот, к примеру, такая...
Мальчик год и месяц. Заболел пять дней назад. Т 39.5, сопли, "свистит". Сегодня появилась сыпь. Известно, что пару дней назад он был осмотрен врачом; был поставлен д-з Пневмония и назначен амоксициллин. Родители амоксициллин не давали, лечили только ингаляциями с альбутеролом. Периодически ребенку делаются такие ингаляции, т.к. он страдает Weezing baby syndrome. При осмотре Т 37.6, ЧДД 45/мин, небольшой инспираторный стридор без выраженного респираторного дистресса. ОАК в норме, СРБ чуть повышен, снимок пневмонию не подтверждает.

Ваши предложения по д-зу:

A. Pityriasis lichenoides et varioliformis acuta (PLEVA)

B. Varicella

C. Viral exanthem due to parainfluenza virus

D. Gianotti-Crosti syndrome

[pretty1984]

Фотки какие то маленькие у меня открываются..Я б за последний ответ проголосовала, может еще какие то факты?:bn:

[ОльгаШа]

Ира, фотки, правда, мелкие. Характер сыпи какой?

Из биохимии только СРБ делали? Или остальное (трансаминазы интересуют) в норме?

[dr.Ira]

Ира, фотки, правда, мелкие. Характер сыпи какой?

Да, картинки маленькие.

Могу только дополнительно добавить, что сыпь описывается, как везикулярная, прививки сделаны все по возрасту, в доме живет собака и кошка, никаких дальних поездок в последнее время не было.
Вот еще про сыпь: The rash was found only on his extremities consists of papular lesions, with brownish-erythematous tops, some of which appeared to have a small central crust.

There was no surrounding erythema, no vesicles seen, and no history of pruritus or evidence of excoriation.
----
Это из серии "задачек", поэтому предполагается, что информации, которая выложена, достаточно для постановки диагноза.

[eduardshraibman]

на сообщение 223, если бы был в ординатуре,ответил бы А., т.к.,на В не похоже,D.может вызываться и при С,а какие то with brownish-erythematous tops, some of which appeared to have a small central при А. описываются, и зуда нет чаще